NCCI


To:

Taylor Richey,

Florida Insure, LLC.

2588 Connection Point, Oviedo, FL 32765

 

From:

Date:

Please accept this as my authorization for you to receive all information, including my experience mod calculation worksheet, from NCCI or other sources as needed in order to prepare an analysis of my workers compensation insurance policy.

Florida Insure LLC http://www.flains.com
Signature Certificate
Document name: NCCI
Unique Document ID: 7535960b79db2df6cb6a96dd3f9fafc049918223
Timestamp Audit
2016-03-17 13:49:34 ESTNCCI Uploaded by Taylor Richey - csr@flains.com IP 1.22.96.79