Prepared by: DIVISION OF WORKERS' COMPENSATION BUREAU OF MONITORING AND AUDIT SELF-INSURANCE SECTION P. O. BOX 5497 TALLAHASSEE,FL 32314-5497 ____________________________________________________________________________ CERTIFICATE OF SELF-INSURANCE NAME AS STATED ON APPLICATION FED. EMP. IDENT. NUMBER WC NUMBER P.O.BOX NO (IF APPLICABLE) STREET ADDRESS CITY STATE LOCATION CODE ZIP CODE DATE RECEIVED EFFECTIVE DATE OF SELF-INSURANCE POLICY NUMBER CARRIER CODE AGENCY RECEIVING OFFICE INDUSTRY NUMBER INSURED OPERATES AS: NATURE OF BUSINESS I-INDIVIDUAL P-PARTNERSHIP C-CORPORATION X-OTHER LEGAL OWNERS: ADDITIONAL NAMED FLORIDA SELF-INSURERS/ADDITIONAL ADDRESSES COMMENTS FORM SI-206 (Rev.9/96) American LegalNet, Inc. www.FormsWorkflow.com