Workers Compensation Certificate Request

Thank you for using SimpleHR's Online Certificate Request Form. Please complete the following information. Then, click submit to send your request to SimpleHR's Workers Compensation Department. Please note that all fields are required. Missing information may result in a processing delay.

Request a Certificate

Your Company Name (Enter the legal name of the SimpleHR client requesting the certificate)

Your Phone Number (Enter phone number of SimpleHR client that is requesting certificate.)

Your Name (Enter first and last name.)

Certificate Holder Full Name

Certificate Holder Mailing Address (Street)

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

Certificate Holder City

Certificate Holder State

Certificate Holder Zip Code

Description (Job Name Listing)

E-mail

Fax

Additional Comments

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Thank you for using SimpleHR's Online Certificate Request Form.

The information you submitted will be processed shortly.

Please call our Workers Compensation Department at 850.650.9935 with any questions regarding your request.

About

SimpleHR is a Professional Employer Organization (PEO) headquartered in Destin, FL, providing cost-effective human resource outsourcing while managing employee risks for client businesses for over 21 years. PEO license number EL374

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36474 Emerald Coast Parkway, Building B
Destin, Florida 32541
Toll Free: (888) 207-6703
Destin: (850) 650-9935
Pensacola: (850) 542-0566
Panama City: (850) 588-0926
Fax: (850) 650-9936
24-Hour Injury Line: (850) 974-2406

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