Fill and Sign the Applicant is a Check One Form

FORM DFS-F2 -SI -22 (8/2009) Rules 69L-5.229 & 69L-5.230 , F.A.C. FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION BUREAU OF MONITORING AND AUDIT SELF-INSURANCE SECTION QUALIFIED SERVICING ENTITY APPLICATION NAME OF APPLICANT: FEIN NUMBER: Applicant is a (Check one) Corporation Individual Proprietor Partnership Other (explain) ADDRES S OF HOME OFFICE (STREET, CITY, STATE, ZIP CODE) ADDRESS OF FLORIDA BRANCH OFFICES NAME OF RESIDENT AGENT ADDRESS OF RESIDENT AGENT IS APPLICANT A SUBSIDIARY? YES NO (If “YES”, complete section belo w) NAME OF PARENT COMPANY TELEPHONE NUMBER (AREA-EXCHANGE) ADDRESS OF PARENT COMPANY (STREET, CITY, ZIP CODE) I _________________________________, c ertify that the information submitted supporting this application is true and correct to the best of my knowledge . The applicant agrees to abide by the provisions of Rule s 69L -5.229 and 69L -5.230 , F.A.C., and all other applicable rules and the Workers' Compensation Law (Chapte r 440, F.S.). ______________________________________ ________________________ _____________ SIGNATURE TITLE DATE INSTRUCTIONS: 1. Attach two (2) letters of reference in accordance with Rule 69L -5.229, F.A.C. 2. Attach summary data and resumes of your pe rsonnel in accordance with the provision of Rule 69L - 5.229 , F.A.C. Include the residence and business address of your personnel on each re sume submitted. 3. Attach a list of all self - insured employers and funds with which you have con tracted or intend to con tract. Indicate what services are to be provided (e.g., claims, safety or all).