Les Form Si-206 - Certificate Of Self-Insurance - Florida Department Of Labor And Employment Security

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FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY
DIVISION OF WORKERS' COMPENSATION
BUREAU OF OPERATIONS SUPPORT
SELF-INSURANCE SECTION
CERTIFICATE OF SELF-INSURANCE
NAME AS STATED ON APPLICATION
FED. EMP. IDENT. NUMBER
WC NUMBER
P.O. BOX NO (IF APPLICABLE)
STREET ADDRESS
CITY
STATE
LOCATION CODE
ZIP CODE
DATE RECEIVED
EFFECTIVE DATE OF SELF-INSURANCE
POLICY NUMBER
CARRIER CODE
AGENCY
RECEIVING OFFICE
INDUSTRY NUMBER
NATURE OF BUSINESS
INSURED
OPERATES AS:
I-INDIVIDUAL
P-PARTNERSHIP
C-CORPORATION
X-OTHER
LEGAL OWNERS
ADDITIONAL NAMED FLORIDA SELF-INSURERS/ADDITIONAL ADDRESSES
COMMENTS
LES Form SI-206 (Rev. 09/96)

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