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<br />I <br /> <br />. <br /> <br />CERTIFICATION OF EMPLOYER WORKPLACE <br />SAFETY PROGRAM PREMIUM CREDIT <br />Employer Name;..Iid-e~-honCl./ ~e...nt.1 C!oni1acJD~/~ <br />Name of Contact Person. _ Iff> x: 6a yoke....... Telephone #: 3oS. 'I'D. G:, 30() <br />Policy # /A.Jc...OO 5.3 / 8Cf g 9 Effective Date of Policy: I }Z I } 2.01 0 <br />.. . <br /> <br />I am submitting a copy of my workplace safety program which meets the reqUirements of Section 440 1025. <br />Florida Statutes. I certIfy that this safety program has been implemented in my workplace and is being <br />maintained as submitted to my carrier. <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 />1) Written salety 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 safely program and application I am submitting for the purpose of obtaining a premium credit do <br />not contain any false. Incomplete. or misleading InfOf'TTlation. I attest to the accuracy of the Information <br />submitted. I am aware that I may be subject to an on-site inspection by my carrier. for the purpose 01 validating <br />the accuracy of this information <br /> <br />I am aware that any person who submits an application that contains false. misleading, or incomplete <br />inlormation provided with the purpose of aVOIding or reducing the amount of premiums for workers' <br />compensation coverage ;$ a felony of the second degree. punishable as provided in Sections 775.082, 775.083 <br />or 775084 Florida Statutes, or as otherwise punishable as provided under the law. <br /> <br />- <br /> <br />/ ./ Slate of Florida ~.L' . k <br />I;. /1' // County of aLdN/- <br /> <br />-;:;~~._/'t~-____ Sworn to, ~~ ~rmed, and subscribed before me <br />, ... .._._.9.9P~> --_ this /?7E!. ~of ~ <br />'1(Ex - 11. g~KfY, Uce t.,.rl 1(....7':20 Il', by r'Ex . ~ <br /> <br />j:~/:::b ~~ <br />, /.... /~M'w <br /> <br /> <br />16".....on 0... Ilt'Id Humt>>.,. <br /> <br />. '1U,,-,.. <br /> <br />8eatriz Baquedano <br />"\'~'I$SI)tl #00686tJ7 <br />. ,'.'Af" JUN. 17,2011 <br />WWW.AARONNOTAIlY.com <br /> <br />(NC3011) <br />Form SAFETY 09-3 <br /> <br />~! <br />.),~ .' <br />',;;;,~"..;.",,\-...' <br /> <br />Q Copyright t.t~200l N'I~.' Council on Compen...tIOftln.unnc:e, Inc. AU R'ghl. __..."'eeI <br /> <br />e <br />