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<br />, <br /> <br />e <br /> <br />CERTIFICATION OF EMPLOYER WORKPLACE <br />SAFETY PROGRAM PREMIUM CREDIT <br /> <br />Employer Name: --bf.M TnlJ.t' ~"T'1"\P~ LJ r_ <br /> <br />Name of Contact Person. !(p}( &. ..- k e V' <br /> <br />Policy/# W<?"oos3L8QgCf <br /> <br />Telephone #: 3oS-l.f'O. ~.30o <br />EHective Date of Policy: I }Z I } 2.01 0 <br />0' . <br /> <br />I am submitting a copy of my workplace safely program which meets the requirements 01 Section 440.1025. <br />Florida Stalutes. I certify thaI this safety program has been Implemented in my workplace and is being <br />maintained as submitted to my carner. <br /> <br />This is to certify that my workplace safety program meets or exceeds the following provisions as provided for in <br />Section 440.1025. Florida Statutes: <br /> <br />1) Written safety policy and safety rules <br />2) Safety inspections <br />3) Preventive maintenance <br />4) Safety training <br /> <br />5) First aid <br />6) Accident investigation <br />7) Necessary record keeping <br /> <br />The workplace safety program and application I am submitting for the purpose of obtaining a premium credit do <br />nol conlain any false. Incomplete. or misleading inlonnalion I attest to the accuracy of the infOf"mation <br />submitted. I am aware that I may be subject to an on-site inspection by my carrier, for the purpose of validating <br />the accuracy of this information. <br /> <br />I am aware that any person wtlo submits an application that contains false, misleading, or incomplete <br />information provided with the purpose of avoidtng or reducing the amount of premiums for workers' <br />compensation coverage is a felony of the second degree, ptlnishable as provided in Sections 775.082, 775.083 <br />or 775.084 Florida Statutes, or as otherwise punishable as provided under the law. <br /> <br />- <br /> <br />I ;/ State of Florida ~ ~. . ~ - <br />/( -;/ County of ~-~ <br /> <br />-,~. -7 . .-?~.. ._ Swo," 10. 0' "",me<!. 00. w,,,<""". be''''. m. <br />( ~.91'~' -.___ this / 1'7l!. ~of ~ <br />"fCc'x 11-.--gvK~J J!,ce ~~.r/'t...7:20IP, by l'7x . <br /> <br />/~i.~::b /~if <br /> <br />g -'!!/ 7~// <br /> <br />fI:ll'pw-,on Dele ..-1(1 Hun~t) <br /> <br />, '10".,_ <br /> <br />8eatriz Baquedano <br />:\'~'ISSl;)N #006861 37 <br />":"nE,: JUN. 17,2011 <br />www.AARQljNoTAJIY.com <br /> <br />(NC3011) <br />Form SAFETY 09-3 <br /> <br />'"! . <br /> <br />~;;i,;,.:, ~:;-,:.: <br /> <br />CI Copyright "'''''2004 NaUon.' Council on Comp.n..tlon Insuranc.. Inc. All Alone. "...rved. <br /> <br />e <br />