Thank you for using Simple HR's Online Certificate Request Form. Please complete the following information.
Then, click submit to send your request to Simple HR's Workers Compensation Department.
Please note that all fields are required. Missing information may result in a processing delay.
   
Client Name (Please type exact legal name
including all DBAs.)
Certificate Holder Full Name

   
Certificate Holder Mailing Address
Certificate Mailing Address 2 (Suite, Apt, etc.)
   
Certificate Holder City

Certificate Holder State

   
Certificate Holder Zip Code
Description (Job Name Listing)
   
Certificate Holder Phone
Certificate Holder Fax
   
   
   

 

Simple HR
(850) 650-9935
toll free (888) 207-6703
info@simplehr.com
 
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