ࡱ> ?A:;<=>'` bjbjLULU .?.? 4$ h\P$ $::(bbb$hd~- ɧ"ɧɧ bbǭǭǭɧ< b bǭɧǭǭW b 0w$S*|0$}"jT `VǭģoX$ɧɧɧɧ$ $ $ s}$ $ $ }$ $ $  State of Florida Department of Business and Professional Regulation Board of Employee Leasing Companies Application for Registration as a Deminimus Employee Leasing Company Form # DBPR ELC 4 DEMINIMUS EMPLOYEE LEASING COMPANY QUALIFICATIONSDeminimus employee leasing companies must be domiciled outside of the state of Florida. Deminimus employee leasing companies must be licensed or registered as an employee leasing company in its state of domicile, if such state requires licensure or registration. Deminimus employee leasing companies shall not have client companies who are domiciled or maintain a principle office located in Florida. Deminimus employee leasing companies may not maintain an office located in Florida. Deminimus employee leasing companies may not advertise or solicit business in any manner from clients who are based in or domiciled in Florida. Deminimus employee leasing companies may not have more than fifty (50) leased employees working in the state of Florida. APPLICATION CHECKLIST IMPORTANT Submit all items on the checklist below with your application to ensure faster processing. APPLICATION REQUIREMENTSALL Deminimus Employee Leasing Company Applicants must submit: Fees: Registration Fee- $250 non-refundable registration fee. Make all checks payable to the Florida Department of Business and Professional Regulation. Complete application form # DBPR ELC 4 Application for Registration as a Deminimus Employee Leasing Company. Complete Section XI- Historical Sketch (pages 12-14). Rule 61G7-5.0012, Florida Administrative Code requires that all applicants complete this form to disclose individuals who directly or indirectly control a specified percentage of voting stock, and/or are directors or principal officers of the applicant or its ultimate parent. The following individuals are required to submit Historical Sketches: Individuals directly or indirectly controlling 20% or more of the voting stock of the applicant or ultimate parent, if the applicant or its ultimate parent is a publicly traded company. Individuals directly or indirectly controlling 10% or more of the voting stock of the applicant or ultimate parent, if the applicant or its ultimate parent is a closely held company. All directors or principal officers of the applicant or its ultimate parent. For more information about Historical Sketch reporting requirements see  HYPERLINK "https://www.flrules.org/gateway/RuleNo.asp?title=APPLICATION%20PROCEDURE&ID=61G7-5.0012" Rule 61G7-5.0012, Florida Administrative Code. Make additional copies as necessary. Complete and sign the Quarterly Compliance Form, Form # DBPR EL 4522, (on page 15 of this packet). Health Insurance Statement (Form # DBPR EL 4507, on page 16 of this packet) completed by your insurance provider stating that the plan of insurance is a fully-insured plan. If the insurance provider refuses to sign the statement, you must provide a complete copy of each health insurance policy. This is only required if providing health insurance to leased employees. Submit all required Exhibits and label them according to their exhibit number. Required Exhibits: Please attach the following documents and label them as the exhibit numbers indicated. Note: ALL exhibits must be attached or enclosed. If the documents requested in a particular exhibit do not apply to you, submit a page referencing that exhibit number and include on that page an explanation as to why the requested information does not apply. Please submit ALL documentation on 8 x 11 paper. Exhibit 1: Certificate of Good Standing or Authority from Florida Secretary of States office. For more information on how to obtain this document, contact the Secretary of State, Division of Corporations at 850.488.9000. Exhibit 2: Workers Compensation Certificate of Insurance (COI). Attach a COI from the workers compensation insurance provider for each policy held. The provider must be an admitted carrier in the State of Florida. The COI must name the employee leasing company as the insured, name the Board of Employee Leasing Companies (including address) as the certificate holder, include a 30-day notice of cancellation, bears the signature of an authorized representative of the insurance provider, and state that it covers all leased employees in this state. Exhibit 3: Copies of UCT-6 Forms. The UCT-6 form is the Florida Department of Revenue Employers Quarterly Report form. This form will be used to determine the amount of assessment due. Please attach a copy of the UCT-6 forms filed with the Florida Department of Revenue for the preceding calendar year. In the event no wages were paid during the preceding calendar year, please provide a statement from management stating such. Exhibit 4: State Taxes Letter of Good Standing. Provide documentation from each state as evidence that payroll taxes, unemployment taxes, etc., are current in those states. Exhibit 5: State License Letter of Verification/Good Standing. Please submit a letter of verification/good standing for each state in which you hold a license to practice as an employee leasing company/group. Exhibit 6: IRS Form 8821. Complete  HYPERLINK "http://www.irs.gov/formspubs/article/0,,id=244720,00.html" IRS Form 8821 for each employee leasing company. Return the completed form(s) with your application. It may be forwarded to the Internal Revenue Service (IRS) for processing. The purpose of this form is to determine if there are any delinquent taxes or penalties due from the employee leasing company. Complete the following items on the form: Instructions for completing IRS Form 8821: Complete the following items on the form: Taxpayer information This must be the name of the applicant. Appointee This must be named Florida Department of Business and Professional Regulation - Employee Leasing Board, 1940 N. Monroe St., Tallahassee, Fla. 32399. Tax matters: The appointee is authorized to inspect and/or receive confidential tax information in any office of the IRS for the tax matters listed on this line. You must list forms 940 and 941 as well as any additional forms the applicant will be filing. Year(s) or period(s) must include the current year, past two (2) years and three (3) future tax periods. Complete # 4 specific use not recorded on centralized authorization file. You must check off # 4 on this section. Instructions If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395. Application Instructions by section Section I- Company Information Fill out each section completely. In the Company Name section, applicants must provide their full legal name as filed with the Secretary of State, Division of Corporations. Do not use any nicknames, aliases, or initials. If your company plans to operate under a fictitious name, list the fictitious name as listed on the certificate from the Secretary of States office that you have been approved to do business under this name. A Federal Employer ID Number (FEID) is required in order to apply for a company license within the Department of Business and Professional Regulation. Provide the Unemployment Tax Identification Number given by the Florida Division of Unemployment Compensation or the Internal Revenue Service. Please select the type of business of the employee leasing company Provide the Corporation Identification Number, Organization Date and Fiscal Year End of company as listed with the Florida Division of Corporations. Provide the state of domicile for the company you are registering. Provide the license or registration number for the company from the state in which it is domiciled. If the state of domicile does not require licensure or registration, please enter Not Required in this section. Answer whether the company provides leased employees to any clients whose business is located, domiciled, or has a principle office in Florida. Answer whether the company maintains an office in Florida. Answer whether the company solicits clients located or domiciled in Florida. Answer whether the company has more than 50 leased employees working in Florida. Provide your mailing address. This will be used for sending correspondence regarding your application and license. Provide the company location address if different from the mailing address. Provide a contact name, valid phone number and email address. Contact information is often used to quickly resolve questions with applications by telephone call or email. If contact information is not provided, questions regarding applications will be mailed to the applicants mailing address and may take longer to resolve. Providing your email address is a public record. Provide the Registered Agent information for the company as designated with the Florida Secretary of States office. Section II- Company Ownership Provide the names, addresses, titles, social security numbers, and percentage of ownership which totals 100% of the companys ownership. Officers, managers, and controlling persons must also provide this information. If already licensed as a controlling person, provide the license number. If not, answer if you will or will not be submitting a controlling person application packet. Section III- Company Background Information Question 1: (a) If you answer yes to this question, you must complete Section IV [make additional copies as necessary] of the application and provide a copy of the arrest report, copies of the disposition or final order(s), and documentation proving all sanctions have been served and satisfied. You must supply this documentation for each occurrence. If you are unable to supply this documentation, a certified statement from the clerk of court for the relevant jurisdiction stating the status of records is required. If you are still on probation, you must supply a letter from your probation officer, on official letterhead, stating the status of your probation. (b) If you answer yes to this question, you must complete Section V [make additional copies as necessary] of the application by explaining the nature of the license, registration or certification refusal. (c) If you answer yes to this question, you must complete Section V [make additional copies as necessary] of the application by providing an explanation for the action against your license and supply copies of the order(s) showing the disciplinary action taken against the license, or documentation showing the status of the pending action. (d) If you answer yes to this question, you must complete Section V [make additional copies as necessary] of the application by explaining the nature of the bankruptcy. If a judgment was entered, please supply documentation proving all sanctions have been served and satisfied, or if not, stating the current status of any proceedings. (e) If you answer yes to this question, you must complete Section V [make additional copies as necessary] of the application by explaining the nature of the case and the allegations made against the entity you were affiliated with. If a judgment was entered against the entity, please supply documentation proving all sanctions have been served and satisfied, or if not, stating the current status of any proceedings. Question 2: If you answer yes to this question, you must complete Section V [make additional copies as necessary] of the application by explaining the reason for investigation or pending disciplinary action. You may be asked to supply copies of documentation ordering the investigation or pending disciplinary action. Question 3: If you answer yes to either 3(a) or 3(b) of this question, you must complete Section VI and VII [make additional copies as necessary] of the application and provide the information asked in the section. Section IV- Explanation(s) for Background Question 1(a) Provide the information requested regarding the offense. Include supporting documentation as requested in Section III. Section V- Explanation(s) for Background Questions 1(b-e) and 2 Provide the information requested regarding the occurrence. Include supporting documentation as requested in Section III. Section VI- Explanation for Background Question 3 Provide the information requested regarding your insurance coverage. Section VII- Health Insurance Information Provide the policy or contract number, name of carrier or service provider, effective dates of coverage, and name and address of agent if you plan to offer health insurance, including dental, to leased employees in the state of Florida. If you answered yes to Question 3 (a) or (b) in Section III this must be completed. Section VIII- Workers Compensation, Unemployment Compensation, and Payroll Tax Disclosure Provide information as it relates to obligations for workers compensation. This includes any amounts under dispute. Provide information about taxes paid to the State of Florida under the unemployment tax account listed on page three (3) of the application. Section IX Affirmation by Written Declaration i. The applicant must sign the affirmation by written declaration. Section X- Historical Sketch This form must be completed by all individuals who directly or indirectly control a specified percentage of voting stock, and/or are directors or principal officers of the applicant or the ultimate parent. Provide the name, date of birth, Social Security number, and relationship to the applicant. Provide the mailing address of the individual completing the historical sketch form. Provide a list of all business entities or organizations with which you are presently affiliated. If you answer yes to any of the background questions, you must provide a statement of the charges and facts of the case, together with the name and location of the courts in which the proceedings were held or are pending. Provide a list of each employer within the past four years. Provide the company name, type of business and address of the employer for which employment is being provided. Provide the individuals title and dates of employment. Section XI- Affirmation by Written Declaration for Historical Sketch The applicant must sign the affirmation by written declaration. State of Florida Department of Business and Professional Regulation Board of Employee Leasing Companies Application for Registration as a Deminimus Employee Leasing Company Form # DBPR ELC 4 [6305/1030] If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395. For additional information see the Instructions at the beginning of this application. Section I Company Information COMPANY INFORMATIONCompany Name:Doing Business As (D/B/A):Federal Employer ID Number (FEID):Unemployment Tax Identification Number:Business Type: ( Sole Proprietor ( LLC ( Corporation (Partnership (Other (please specify): Corporation Identification Number with Florida Division of Corporations:Organization Date:Fiscal Year End:State of Domicile:License/Registration Number:Does Company provide leased employees to a client whose business is located, domiciled, or has a principle office located within Florida? ( Yes ( No Does Company maintain an office in Florida? ( Yes ( No Does Company solicit clients located or domiciled in Florida? ( Yes ( No Does Company have more than 50 leased employees working in Florida? ( Yes ( No MAILING ADDRESSStreet Address or P.O. BoxCityStateZip Code County (if Florida address)CountryCOMPANY LOCATION ADDRESSStreet AddressCityStateZip Code County (if Florida address)CountryCOMPANY CONTACT INFORMATIONContact Name:Phone Number of ContactE-Mail Address of Contact (optional)REGISTERED AGENT INFORMATIONName of Registered Agent:Street Address or P.O. BoxCityStateZip Code County (if Florida address)CountrySection II Company Ownership (attach additional copies as necessary) OWNER INFORMATIONOWNERS, OFFICERS AND MANAGERS- Please print below the names, mailing addresses, titles and percentage of ownership and telephone numbers of each person. CORPORATION- If the applicant is owned by another corporate entity, attach a separate schedule providing information on the officers of the parent firm(s) and ultimate owners (natural persons), as indicated above.OWNERSHIP INFORMATIONLast Name First Middle SuffixAddressTitleSocial Security NumberTelephone NumberPercentage Of Ownership %Licensed as Controlling Person: ( Yes ( No If Yes, provide license number:______________ Will you submit a controlling person application with this packet: ( Yes ( No OWNERSHIP INFORMATIONLast Name First Middle SuffixAddressTitleSocial Security NumberTelephone NumberPercentage Of Ownership %Licensed as Controlling Person: ( Yes ( No If Yes, provide license number:______________ Will you submit a controlling person application with this packet: ( Yes ( No OWNERSHIP INFORMATIONLast Name First Middle SuffixAddressTitleSocial Security NumberTelephone NumberPercentage Of Ownership %Licensed as Controlling Person: ( Yes ( No If Yes, provide license number:______________ Will you submit a controlling person application with this packet: ( Yes ( No OWNERSHIP INFORMATIONLast Name First Middle SuffixAddressTitleSocial Security NumberTelephone NumberPercentage Of Ownership %Licensed as Controlling Person: ( Yes ( No If Yes, provide license number:______________ Will you submit a controlling person application with this packet: ( Yes ( No OWNERSHIP INFORMATIONLast Name First Middle SuffixAddressTitleSocial Security NumberTelephone NumberPercentage Of Ownership %Licensed as Controlling Person: ( Yes ( No If Yes, provide license number:______________ Will you submit a controlling person application with this packet: ( Yes ( No *Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless specifically required by Federal statute. In this instance, Social Security numbers are mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and Sections 455.203(9), 409.2577, and 409.2598, Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and will be used for licensee identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193, Sec. 317. Section III Company Background Information COMPANY BACKGROUND INFORMATIONHas the company, any controlling person, or any owner of the company:1.Yes ( (If yes, please complete Section IV)No ((a) Ever been convicted or found guilty -regardless of adjudication- of a crime in any jurisdiction, or have you ever been a defendant in a military court martial? (Do not include parking or speeding violations.) Yes ( (If yes, please complete Section V)No ((b) Ever been refused a professional license, registration or certification in any state?Yes ( (If yes, please complete Section V)No ((c) Ever had a professional license, registration or certification revoked, suspended, or otherwise acted against including probation, fine, or reprimand in a disciplinary proceeding in any state?Yes ( (If yes, please complete Section V)No ((d) Ever filed for protection under the Bankruptcy Act?Yes ( (If yes, please complete Section V)No ((e) Ever been involved in or owned an interest in an entity that has been adjudicated bankrupt, filed proceedings under the Bankruptcy Act, or otherwise closed due to insolvency?2.Yes ( (If yes, please complete Section V)No (Is any employee leasing company (or other professional) license, registration or certification under investigation or pending disciplinary action in any state? 3.Yes ( No (Are benefits provided to any leased employees in the State of Florida for life, health or disability claims? Yes ( No ((a) Are you currently providing coverage to any leased employees in the State of Florida under a plan which is not fully insured?Yes ( No ((b) Are you currently providing coverage to any leased employees outside the State of Florida under a plan which is not fully insured?Yes (No ((c) Do you plan to provide coverage in the State of Florida within three months of being licensed? If you answered YES to questions 1 2 above, please provide the full details of any criminal conviction, lawsuit or judgment, or administrative action including the nature of any charges, dates, outcomes, sentences, and/or conditions imposed; the dates, name and location of the court and/or jurisdiction in which any proceedings were held or are pending; and the designation and/or license number for any actions against a license or licensure application. Please utilize Section IV for your responses to question 1(a) and Section V for your responses to questions 1(b-e) and 2. If you need additional response sections for Section IV or V, please make additional copies of those sections and submit them with your application. Section IV Explanation(s) for Background Question 1 EXPLANATIONOffenseCountyStatePenalty/DispositionDate of Offense (MM/DD/YYYY) / /Have all sanctions been satisfied? ( Yes ( NoDescription EXPLANATIONOffenseCountyStatePenalty/DispositionDate of Offense (MM/DD/YYYY) / /Have all sanctions been satisfied? ( Yes ( NoDescription EXPLANATIONOffenseCountyStatePenalty/DispositionDate of Offense (MM/DD/YYYY) / /Have all sanctions been satisfied? ( Yes ( NoDescription Section V Explanation(s) for Background Questions 1(b-e) and 2 EXPLANATIONState/Jurisdiction: Application Type/License Number: Section V Explanation(s) for Background Questions 1(b-e) and 2 EXPLANATIONState/Jurisdiction: Application Type/License Number: Section VI Explanation for Background Question 3 EXPLANATION FOR BACKGROUND QUESTION 3If you checked YES for either 3(a) or 3(b), please provide the following information:Name of Insurance Company and/or TPA AddressPhone #CityStateZip Code *Stop Loss Carrier Specific Stop Loss Limit $*Do you carry aggregate stop loss insurance? ( No (Yes If you checked YES above, what is the aggregate attachment point?Are reserves for claims included in applicant's financial statements submitted with this application? ( No (YesEnding date of the plan year:Date of last IRS form 5500 filed:For plan year ended:*If no specific or aggregate stop loss insurance, attach actuarial computation attested by certified actuary as to current liability under the plan. Section VII Health Insurance Information HEALTH INSURANCE SCHEDULE (including Dental)COMPLETE THE INSURANCE SCHEDULE BELOW LISTING ALL PLANS OFFERED to leased employees in the state of Florida including: policy or contract number, name and address of the carrier or service provider, effective dates of coverage, name and address of agent, name of plan sponsor, and ERISA plan identification number.Plans of Insurance offered by: (Name of Applicant)Policy NumberCarrier/PlanEffective Dates To-FromName & Address of AgentIF ANY INFORMATION ON THE APPLICATION CHANGES, THE APPLICANT OR LICENSEE SHALL SUBMIT SUCH CHANGES TO THE DEPARTMENT WITHIN THIRTY (30) DAYS AFTER THE DATE OF SUCH CHANGE. Section VIII Workers Compensation, Unemployment Compensation, and Payroll Tax Disclosure WORKERS COMPENSATIONSection 468.529(4), Florida Statues, requires that all obligations for workers compensation be paid at the time of application except for amounts under dispute. Amounts under dispute must be disclosed on the application. All premiums due as of this date have been fully paid to all Workers Compensation insurance carriers: ( Yes ( NoIf No, please disclose all disputed premiums below:CarrierPolicy NumberPeriod CoveredDisputed Amount UNEMPLOYMENT COMPENSATION AND PAYROLL TAXESSection 468.529(4), Florida Statues, requires that all obligations for payroll related taxes be paid at the time of application. Delinquent amounts and any amounts under dispute must be disclosed on the application. All State and Federal payroll related tax obligations due as of this date have been fully paid: ( Yes ( NoIf No, please disclose all delinquent or disputed amounts below:State/FederalPeriod CoveredAmountDisputed/DelinquentRepayment Planq Disputed q Delinquentq Yes q Noq Disputed q Delinquentq Yes q Noq Disputed q Delinquentq Yes q Noq Disputed q Delinquentq Yes q Noq Disputed q Delinquentq Yes q No Section IX  Affirmation by Written Declaration AFFIRMATION BY WRITTEN DECLARATION I certify that I am empowered to execute this application as required by Section 559.79, Florida Statutes.I understand that my signature on this written declaration has the same legal effect as an oath or affirmation. Under penalties of perjury, I declare that I have read the foregoing application and the facts stated in it are true. I understand that falsification of any material information on this application may result in criminal penalty or administrative action, including a fine, suspension or revocation of the license. Signature:Date:Print Name: Section X Historical Sketch Rule 61G7-5.0012, Florida Administrative Code requires that all applicants complete this form to disclose individuals who directly or indirectly control a specified percentage of voting stock, and/or are directors or principal officers of the applicant or its ultimate parent. The following individuals are required to submit Historical Sketches: Individuals directly or indirectly controlling 20% or more of the voting stock of the applicant or ultimate parent, if the applicant or its ultimate parent is a publicly traded company. Individuals directly or indirectly controlling 10% or more of the voting stock of the applicant or ultimate parent, if the applicant or its ultimate parent is a closely held company. All directors or principal officers of the applicant or its ultimate parent. For more information about Historical Sketch reporting requirements see  HYPERLINK "https://www.flrules.org/gateway/RuleNo.asp?title=APPLICATION%20PROCEDURE&ID=61G7-5.0012" Rule 61G7-5.0012, Florida Administrative Code. NOTE: Any individual who holds a current controlling person license or who will be submitting a controlling person application with this packet DOES NOT need to complete a historical sketch. PERSONAL INFORMATIONI, _________________________________, submit the following information to the Department of Business and Professional Regulation and the Board of Employee Leasing Companies for its use as a part of the employee leasing company license application filed by__________________________________, pursuant to Chapter 468, Florida Statutes.Other names by which you have been known:Date of BirthSocial Security Number*Relationship to Applicant: (Office held, % of ownership, etc.)MAILING ADDRESSStreet Address or P.O. BoxCityStateZip Code (+4 optional)County CountryOTHER BUSINESS AFFILIATIONSProvide a list of all business entities or organizations with which you are presently affiliated. Attach additional list if necessary. If none, so state.Business Name & LocationNature of BusinessAffiliation*Under the Federal Privacy Act, disclosure of Social Security Numbers is voluntary unless specifically required by Federal Statute. In this instance, Social Security Numbers are mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and sections 455.203(9), 409.2577, and 409.2598, Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations, Social Security Numbers must also be recorded on all professional and occupational license applications and will be used for licensee identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193, Sec 317. Section X Historical Sketch (continued) BACKGROUND QUESTIONSHave you, or any entity of which you are, or were then, a principal officer, director, or principal, been the subject of a governmental enforcement action within the last seven years?( Yes ( No Have you, or any entity of which you are, or were then, a principal officer, director, or principal, had a license to operate revoked, suspended, denied, or otherwise acted against within the last seven years?( Yes ( No Have you, or any entity of which you are, or were then, a principal officer, director, or principal, been subject to bankruptcy proceedings or had a judgment filed against you or the entity, either present, past or pending?( Yes ( No If any of the questions above are answered YES, please provide a statement of the charges and facts of the case(s), together with the name and location of the court(s) in which the proceedings were held or are pending.By affixing my signature to this form, I hereby agree that the Department of Business and Professional Regulation and the Board of Employee Leasing Companies may make full inquiry of each of the below named persons and all former employers and all other persons concerning my business, professional or moral character and reputation, including the procurement of letters, statements or affidavits concerning the same that may be deemed pertinent to a determination of my qualifications for registration under Chapter 468, Florida Statutes, and do specifically waive all claims, damages, rights of action or causes of action that might otherwise accrue to me against any of said persons, resulting or arising from, or by reason of, any and all statements of fact or opinion given in good faith concerning me expressed by any of them in reply to any inquiry made by, or under direction of, the department or the board, whether the same be responsive to, or necessarily required by, such inquiry or not, and that all such statements shall be deemed privileged and not actionable by me unless such statements are, in fact, willfully made and falsely given with malice toward me. I understand that this inquiry may include a criminal background check through the Florida Department of Law Enforcement and the National Criminal Information Center (NCIC).EMPLOYMENT HISTORY Provide your employment history for the past ten (10) years. Name of Present or Last EmployerType of Business Address (Street and Number)CityStateZip Code (+4 optional)Your Job TitleDates of Employment From:____/____/_____ To:____/____/_____EMPLOYMENT HISTORY Provide your employment history for the past ten (10) years. Name of Present or Last EmployerType of Business Address (Street and Number)CityStateZip Code (+4 optional)Your Job TitleDates of Employment From:____/____/_____ To:____/____/_____ Section X Historical Sketch (Employment History continued) EMPLOYMENT HISTORY Provide your employment history for the past ten (10) years. Name of Present or Last EmployerType of Business Address (Street and Number)CityStateZip Code (+4 optional)Your Job TitleDates of Employment From:____/____/_____ To:____/____/_____EMPLOYMENT HISTORY Provide your employment history for the past ten (10) years. Name of Present or Last EmployerType of Business Address (Street and Number)CityStateZip Code (+4 optional)Your Job TitleDates of Employment From:____/____/_____ To:____/____/_____ Section XI Affirmation by Written Declaration For Historical Sketch AFFIRMATION BY WRITTEN DECLARATION I certify that I am empowered to execute this application as required by Section 559.79, Florida Statutes.I understand that my signature on this written declaration has the same legal effect as an oath or affirmation. Under penalties of perjury, I declare that I have read the foregoing application and the facts stated in it are true. I understand that falsification of any material information on this application may result in criminal penalty or administrative action, including a fine, suspension or revocation of the license. Signature:Date:Print Name: State of Florida Department of Business and Professional Regulation Board of Employee Leasing Companies Quarterly Compliance Form Form # DBPR EL 4522 as part of ELC 4 The undersigned persons hereby certify that they have made due inquiry of their employee leasing company or groups books and records and that after making such due inquiry, the undersigned persons have taken reasonable steps, as set forth in Rules 61G7-10.0014(3)(b)1-2, Florida Administrative Code to ascertain that all leased employees of their employee leasing company or group have workers compensation coverage as required by Rules 61G7-10.0014(2)(a)-(c), Florida Administrative Code. The percentage of leased employees in the State of Florida who are covered by each of the methods set forth in Rule 61G7-10.0014(2)(a)-(c), Florida Administrative Code, are as follows: Through a contractual relationship between the employee leasing company or group and an insurance carrier that is admitted in the State of Florida to provide workers compensation coverage to leased employees: ___________ percent. Set forth carrier name and workers compensation policy numbers: ______________________________________________ _______________________________________________________________________ Through a lawful plan of self-insurance maintained by the employee leasing company or group which provides workers compensation coverage to leased employees: _________ percent. Through the client of the employee leasing company or group via an insurance carrier that is admitted in the State of Florida to provide workers compensation coverage to leased employees or through a lawful plan of self-insurance maintained by a client of the employee leasing company or group which provides workers compensation coverage to leased employees: ___________ percent. Set forth all clients names (named insured) utilizing their own workers compensation policy, the carriers names, the effective date of the policy, the expiration date of the policy, and the workers compensation policy numbers: _____________________________________ ________________________________________________________________________ For any client which utilizes a workers compensation policy or plan of self-insurance maintained by the client, the undersigned persons have verified that the written employee leasing contract between the employee leasing company and the client specifically authorizes this lawful arrangement. Also, the undersigned persons have verified the employee leasing company is named as a certificate holder by the client on the workers compensation policy maintained by the client. Additionally, where the client maintains its own workers compensation policy or lawful plan of self-insurance, the undersigned persons have verified that the employee leasing company has provided notice to the leased employees that workers compensation coverage is being provided by the client. Set forth all other workers compensation arrangements: _________ percent. Explain any such arrangement in detail. The following persons understand and agree that they: have executed this document for and on behalf of the employee leasing company or group named above; that they are all of the controlling persons, the Chief Executive Officer, the Chief Financial Officer and the Chairman of the Board of the employee leasing company or group, that each is fully authorized to execute and file this statement; and that to the best of their knowledge, the information contained in the attestation statement is true and correct. ____________________________________ ______________________________________ Chief Executive Officer Print Name ____________________________________ ______________________________________ Chairman of the Board Print Name ____________________________________ ______________________________________ Chief Financial Officer Print Name ____________________________________ ______________________________________ Controlling Person Print Name State of Florida Department of Business and Professional Regulation Board of Employee Leasing Companies Health Insurance Statement Form # DBPR EL 4507 as part of ELC 4 If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395. TO BE COMPLETED BY REPRESENTATIVE OF INSURANCE CARRIER (INSURER)I, , state: I am employed by ____________________________________________ (name of employer), as (position). __________________________(name of employer), is an admitted insurance carrier in the State of Florida. I possess the authority to make the following statements on behalf of __________________________(name of employer) and to bind __________________________(name of employer) concerning the statements made herein. It is my understanding that, as a requirement for licensure as an employee leasing company in Florida, an employee leasing company may not sponsor a plan of self-insurance for health benefits except as may be permitted by the provisions of the Florida Insurance Code or, if applicable, by Pub. L. No. 93-406, the Employees Retirement Income Security Act. _________________________________________________ (name of insurer) Group Insurance Policy # , issued to _____________________________ (name of leasing company), is in compliance with the requirements of this law as it is a fully insured insurance product which is fully insured by _____________________________ (name of insurer). Notwithstanding any provision in this policy which could be interpreted to the contrary, ________________________ (name of insurer) is ultimately fully responsible for all incurred claims under the terms of the policy. Signature of Insurance Personnel Please send the completed form to: Department of Business and Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-0783 www.MyFloridaLicense.com      PAGE 1 of  NUMPAGES 16 DBPR ELC 4 Registration as a Deminimus Company 2013 August Incorporated by Rule: 61-35.013 DBPR ELC 4 Registration as a Deminimus Company 2013 August Incorporated by Rule: 61-35.013 DBPR ELC 4 Registration as a Deminimus Company 2013 August Incorporated by Rule: 61-35.013 x+ 2 K L ɸɸɖo[oKo8$hte=hXCJOJPJQJ^JaJhACJOJPJQJ^JaJ'hX56>*CJOJPJQJ^JaJhXCJOJPJQJ^JaJ-hte=hA5CJOJPJQJ\]^JaJ!hA5CJOJPJQJ^JaJ!hr55CJOJPJQJ^JaJ!hte=5CJOJPJQJ^JaJ!h;{5CJOJPJQJ^JaJ!hX5CJOJPJQJ^JaJ'hte=hte=5CJOJPJQJ^JaJDhUwkd$$IfTl    ;$%  0    %4 lap ytPT$$$@&Ifa$gdf $gdA $ $a$gdte=$ H$a$gdte=٥L i c | v$$$@&Ifa$gdfgdte=gkd$$IfTl    $%0    %4 laytAT & F$IfgdA c } T 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