Free SI-206 - Florida

Prepared by: DIVISION OF WORKERS' COMPENSATION BUREAU OF MONITORING AND AUDIT SELF-INSURANCE SECTION P. O. BOX 5497 TALLAHASSEE,FL 32314-5497 ____________________________________________________________________________ CERTIFICATE OF SELF-INSURANCE
NAME AS STATED ON APPLICATION FED. EMP. IDENT. NUMBER STREET ADDRESS STATE DATE RECEIVED POLICY NUMBER LOCATION CODE WC NUMBER P.O.BOX NO (IF APPLICABLE) CITY ZIP CODE

EFFECTIVE DATE OF SELF-INSURANCE

CARRIER CODE RECEIVING OFFICE INDUSTRY NUMBER INSURED OPERATES AS: NATURE OF BUSINESS

AGENCY

I-INDIVIDUAL

P-PARTNERSHIP

C-CORPORATION

X-OTHER

LEGAL OWNERS:

ADDITIONAL NAMED FLORIDA SELF-INSURERS/ADDITIONAL ADDRESSES

COMMENTS

FORM SI-206 (Rev.9/96)