Claims Database Registration Form - Florida Workers' Compensation

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Florida Workers’ Compensation
Claims Database Registration Form
Company Name *
Federal Employer Identification Number *
Address *
City *
State *
Zip Code +4 *
Phone Number *
Fax Number
Type of Business *
E- Mail Contact
Authorized Users *
SSN *
E- Mail Address
Company ID
Florida Workers' Compensation Use
User PIN
Only
As Owner or Corporate Officer of the above named Company, I give my author ization for the persons named above to be registered users of the Florida Workers’
.
Compensation Claims Database. I understand that any authorized user who fails to access the database in any six -month period will be automatically de- authorized
Owner or Corporate Officer *
Authorized Signature *
Authorization Date *
Approved By
Approval Date
Florida Workers' Compensation Use Only
* Required Fields
Pg. 2
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