📄 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
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EFTA00313997
Dataset
DataSet-9
Document Type
document
Pages
1
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