EFTA00313996
EFTA00313997 DataSet-9
EFTA00313998

EFTA00313997.pdf

DataSet-9 1 page 789 words document
P17 V16 V11 D1 P21
Open PDF directly ↗ View extracted text
👁 1 💬 0
📄 Extracted Text (789 words)
1184674 kaolin* LLC Ac 130 FL (Page 3 ol 3) 3/12/2019 52740 PM µY PERSON MO KNOWINGLY AND WITH Waif TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES COP/TARING µY FALSE, INCOMPLETE OR MISLEAD A STATEMENT OF CLAW OR AN APPLICATION ING INFORMATION IS GUILTY OF OF THE THIRD DEGREE OR AS OTHERWISE PUNISHA PROVIDED UNDER DIE LAW. SLE AS I UNDERSTµD THAT AS THE EMPLOYER, I MUST UPDATE THE APPUCATON MONTHLY TO REELECT ANY CHANGE IN THE REQUIRED APPLICATION COMPENSATION DOME SHEET WELL BE USED FOR %FORMATION ITHE FLORES WORKERS THIS PURPOSE ) F I FEE M APPLICATION OR APPLICATION UPDATE CCRiTAINOC FALSE MIS/ FADING. CR INCOMPLETE WECRM REDUCING DIE ANOINT Of PREMIUM FOR WORKER ATICN WITH THE PURPOSE OF AVCICINO CR S COMPENSATION covert/cc IT TS A FELCNY OF AS PROACE0 LADER THE LAW. THE THRO DEGREE CR 45 OT1121111SE PUNISHASLE I SHALL SUOMI TO THE CARRIER, A COPY OF I Ht EMPLOYERS QUARTERLY REPORT MID SELF-AUDITS REPORT) AS REQUIRED BY CHAPTER 443, AT DIE END SUPPORTED BY THE EMPLOYERS QUARTERLY OF EACH QUARTER Islas,' THE MSC OF Ah EATIALOY REPORT. FLORIDA STATUTES STATE THAT I WC. REMAIN EE FROM DIS EMPLOYERS OLORTEFLLY LIABLE AND WILL RE MOURSE THE CARRTER FOR ANY THIS OMITTED EMPLOYEE; WORREP25 COMPENSADJN BENEFITS PAD TO I AGREE TO MARE AVAILABLE. ALL RECORDS NECESS ARY FOR THE PAYROLL VERIFICADON ALOT AND INSPECTION OF CUR OPERATIONS I LWEERSTANO PEEWIT THE AUDITOR TO MAKE A PHYSICAL FAILURE TO DO THIS SHALL RESULT N A 5600 PAYMENT TO ALEC& TIC CARRIER TO CEFRAY THE COST OF THE THAT, IN ACCCRDµCE STEN FLORJOA STATUT ES 440-131/5), F I ME) UNDERSTATE OR COErELL PAYROL DUTIES SO AS TO AVOID PROPER CLASSMATE:11 L. OR mEINERNEsENT OR CONCEAL ompLoygE FOR PREMLAI CALCULATIONS. OR MISREPRESENT COMPUTATION AND APPLICATOR CO NI EXPERIENCE CR CONCEAL NFORMATIOX PERTH ENI TO THE RATING LIODFCATION FACTOR I DYE) SHALL PAY A DIFFERENCE RI PREMIUM PAL) MD THE AMOUNT PENALTY OF TEN (10) TIES THE AMOUNT Of THE I ENE) SHOULD HAVE PALO. MD REASON ILL ATTORN EYS FEES. FORMER NAVES MD OWNERS FOR THE LAST S YEARS, LIST THE CURRENT BUSINESS NAM COVERED BY THE POLICY INCLUDE THE PEN FOR EACH COLEMA µD ANY FORMER NAMES OR PREDECESSOR COMPANIES FOR AL_ CCMPAMES TO RE N'. FOR EACH COVERED COMPANY. LEST Mn OAREN T OWNER WHO -AS MORE THAN 5% CMTENS COMPANY OR PREDECESSOR COMPANY. LAST NAY OVOIER IIIP INTEREST Fag EACH COVERED WHO HAD HIRE THAN 5% OWNER:SHP INTEREST IN THE LAST S YEARS. CWNERSHIP I CCAESHABicry DOES TE48 04ISIXESS OR µY OF THE CWWERS OF THIS BUSINESS. EITHER IMONICLOALY OR N COMBINATION OWN MORE THAN 50% OF ANY OTHER BIGNES WITH OTHER OWNERS OF THIS BUSINESS S, ANKH/ OPERATED AT µY THE CORING THE FIVE YEµS PRIOR TO THIS APPLICATION, I- - OR, DOES TIES Er-SWESs OWN A MA.CRITY INTERES T N ANOTHER EMPTY, WIRCHNT-RN OARS A MAJORIT YES a NO µY TIME IN THE FEE YEARS PRIOR 10 THIS APPLICA Y INTEREST IN ANY ENTITY THAT OPERATED r TION? n YES n NO IF THE ANSWER TO EITHER CF TIE ABOVE QUESTIONS IS YCS. COMPLETE THE MEOWING SUPPLEMENTAL OYWIERSHW / OCARINAS*.ITY QuESTEC EES. I Dec lEy BY NAME ACCREss. AND FEIN EAC- MANESS WHICH FS RELATED or comma.. DANERstip TO THE APPLICA NT EwsiNtss 2. SET FORTH DE DATES CACH BUSINESS WAS IN OPERATION. THE INSURANCE ccupAwy THAT PROVIDED POLICY NuMBER AND THE EXPERTENCE WOCKFIC WORKERS' CCEAPENSATON NS -RMCE. THE ATEON FACTCR APPLIED TO EACH SUCH POLICY 1 F THE POLICE, WAS wRTTEN WITHOLLT AN EXPERIE NCE MODIRADON FACTOR, P‘LASE STATE, THE APPLICANT HEREBY AUTHORIZES AND REO.ES TS EACH RATING ORGANIZATION WITH I- YFEPIPNCE µD THE NOSINESS SET FORTH ABOVE TO RELEAS RATIO INFORAMTON RELATED TO THE APPLICANT E SUCH INFORMATION TO THE INSURE.R. POICJUA CORRECT VIPER/MEE 1130FICATION FACTOR , OR OTHER RATIWZ ORGµIZATION SO THAT Cµ BE DETERMINED. THE I HEREBY ACKNOTILEDGE THAT I HAVE READ THE AbOVE AB AGENT PERSONALLY SWEAR PRAT THE INFORMATION STATEMENTS AND I PRODUCERI HEREIN Ann? THA- I HAVE APPLICATION IS ACCURATE. THAT I. AS AN OWNER IMtTAP/ED IN THE -ar -,- GIVEN )EIGHNICTRY THE °PPM/LT.1TV TO READ TIE APPLICATION THE OFFICER, AM FLtLY HAVE EXPLAINED ANY AM ALL WESTON'S REGARDING THE APPLICATION EACI I AUTHORIZE() TO SIGN THIS APPIJOATION ON ALSO ATTEST THAT /HAVE EXPLANED TO THE I BEHALF OF THE APPOCANT EMPLOYER OR OFFICER THE AND TO SEC THE APPLCMT. CLASSIFICATION COCOS THAT Aft USED FOR PREMIUM PURSLµT TO SECTION 440Sn 42) FLORDA CALCUL ATIONS ONO / STATUTES BALI MamaRSFend IOW rev C8AA/<37 WC 0411 NOTATMEUOu0 MEATUS A DATE i Ak-t4A Diu}h lii ii , L Paw SMS -LESLEY K. NOTARY PUBLIC-STATE OF NEW YORK No 01GR6285700 Ovelitied In New YOni County gyeommission Exp•res 07-08.2021 EFTA00313997
ℹ️ Document Details
SHA-256
54d731930b23fa4d4ea55175029a3d2b9575558d24bd36c9fb988be890805670
Bates Number
EFTA00313997
Dataset
DataSet-9
Document Type
document
Pages
1

Comments 0

Loading comments…
Link copied!