Fill and Sign the Drug Free Application Form09 1a Effective 110119 1

NOTICE TO EMPLOYER: If you have a Drug-Free Workplace Program established and maintained in accordance with Florida law, and you would like to apply for the 5% premium credit that is available, please complete this form and forward it to your insurer. Re-certification is required annually. APPLICATION FOR DRUG-FREE WORKPLACE PREMIUM CREDIT PROGRAM Name of Employer: Date Program Implemented: Testing: Procedures for drug testing have been established and/or drug testing has been conducted in the following areas: Job applicant Routine fitness for duty Reasonable suspicion Follow-up testing to Employee Assistance Program Notice of Employer’s Drug Testing Policy: Copy to all employees prior to testing Show notice of drug testing on vacancy Posted on employer’s premises announcements Copy to job applicants prior to testing Copies available in personnel office or General notice given 60 days prior to testing other suitable locations No notice required because the employer had a drug testing program in place prior to July 1, 1990 Education: Resource file on providers Employee Assistance Program Education Name of Medical Review Officer: A. Name of approved Agency for Health Care Administration Lab or United States Department o f Health and Human Services Certified Laboratory: B. Phone No.: ( ) C. Address : Your certification is subject to physical verification by the insurer. Your policy is subject to additional premium for reimbursement of premium credit, and cancellation provisions of the policy if it is determined that you misrepresented your compliance with Florida law. Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Employer Name Date Officer/Owner Signature* Title * Application must be signed by an officer or owner. THE ABOVE SIGNED CERTIFIES THAT THIS INFORMATION IS A TRUE AND FACTUAL DEPICTION OF THEIR CURRENT PROGRAM. Notary Public’s Signature Date Expiration of Commission (NC3010) Form 09-1