Floridaprofessionallicenseattorney wpSTATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the name of the contractor or corporation in the designated field. Ensure accuracy as this information is crucial for identification.
3. Input the Social Security or License Number in the next field. This helps verify the contractor's credentials.
4. Fill in the Insurance Company Name and provide details of your local insurance agent or representative, including their contact information.
5. Complete both home office and office addresses, ensuring that city, state, and zip code are correctly entered for each location.
6. Enter telephone numbers for both the contractor and insurance representative to facilitate communication.
7. Specify the Workers’ Compensation Policy Number along with its effective dates, indicating when coverage begins and ends.
8. Finally, have an authorized insurance representative sign the form, print their name, and include their email address along with the date signed.

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