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NATIONAL COUNCIL ON COMPENSATION INSURANCE,INC. 06-FL-2004 <br /> ITEM 06-FL-2004—FLORIDA DRUG-FREE WORKPLACE PREMIUM CREDIT PROGRAM <br /> NOTICE TO EMPLOYER: If you have a Drug-Free Workplace Program established and maintained in accordance <br /> with Florida law,and you would like to apply for the 5%premium credit that is available,please complete:this>form <br /> and forward it to your insurer. Re-certification is required annually. <br /> APPLICATION FOR DRUG-FREE WORKPLACE PREMIUM CREDIT PROGRAM <br /> Name of Employer: <br /> Date Program Implemented: <br /> Testing: <br /> Procedures for drug testing have been established and/or drug testing has been conducted in the following areas: <br /> _Job Applicant _Routine fitness for duty <br /> Reasonable suspicion _Follow-up testing to Employee Assistant Program <br /> Notice of Employer's Drug Testing Policy: <br /> _Copy to all employees prior to testing _Show notice of drug testing on vacancy announcements <br /> Posted on employer's premises Copies available in personnel office or other suitable locations <br /> Copy to job applicants prior to testing No notice required because the employer had a drug testing <br /> program in place prior to July I, 1990 <br /> General notice given 60 days prior to testing <br /> Education: <br /> Resource file on providers <br /> _Employee Assistance Program <br /> Education <br /> Name of Medical Review Officer: <br /> A.Name of approved Agency for Health Care Administration Lab or United States Department of Health and Human <br /> Services Certified Laboratory: <br /> B.Phone No: <br /> C. Address: <br /> Your certification:is.subject to_physical verification by:the insurer- Your oli_cy is subject to additional premium for <br /> reimbursement of premium credit and cancellation provisiotts of the polio if it=als determined that you <br /> misrepresented your compliance with Florida law. Any person who knowingly and with intent to injure,defraud or <br /> deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading <br /> information is guilty of a felony of the third degree. <br /> Employer Name Date Officer/Owner Signature" <br /> Title <br /> *Application must be signed by an officer or owner. <br /> THE ABOVE SIGNED CERTIFIES THAT THIS INFORMATION IS A TRUE AND FACTUAL DEPICTION OF <br /> THEIR CURRENT PROGRAM. <br /> Notary Public's Signature Date Expiration of Commission <br /> (NC3010) <br /> Form 09-01 <br /> C 2004 National Council on Compensation Insurance,Inc. <br /> 38 <br />