Qualified Servicing Entity Application {SI-22}

FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION BUREAU OF MONITORING AND AUDIT SELF-INSURANCE SECTION QUALIFIED SERVICING ENTITY APPLICATION NAME OF APPLICANT: Applicant is a (Check one) Corporation Individual Proprietor FEIN NUMBER: Partnership Other (explain) ADDRESS 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? NAME OF PARENT COMPANY YES NO (If "YES", complete section below) TELEPHONE NUMBER (AREA-EXCHANGE) ADDRESS OF PARENT COMPANY (STREET, CITY, ZIP CODE) I _________________________________, certify 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 Rules 69L-5.229 and 69L-5.230, F.A.C., and all other applicable rules and the Workers' Compensation Law (Chapter 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 personnel in accordance with the provision of Rule 69L5.229, F.A.C. Include the residence and business address of your personnel on each resume submitted. 3. Attach a list of all self-insured employers and funds with which you have contracted or intend to contract. Indicate what services are to be provided (e.g., claims, safety or all). FORM DFS-F2-SI-22 (8/2009) Rules 69L-5.229 & 69L-5.230, F.A.C. American LegalNet, Inc. www.FormsWorkFlow.com