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Employee Assistance Program
54 Education
NOTICE TO EMPLOYER; if you have a Drug -Free Workplace Program established and maintained in ac-
cordance with Florida law, and you would like to apply for the 5% premium credit that is available, please
complete this form and forward it to your insurer. Re -certification is required annually,
APPLICATION FOR DRUG -FREE WORKPLACE PREMIUM CREDIT PROGRAM
Name of Employer: r'.nmmarrta 1 F.nergY Specialists, Inc,
860 Jupiter Park Dr., Jupiter, FL 33458
Date Program Implemented: Mcf4- (4,s,(2._ L 0 a)crct
Testing: l
Procedures for drug testing have been established and/or drug testing has been conducted In the following areas:
1 Job applicant ❑ Routine fitness for duty
Reasonable suspicion IiiFollow-up testing to Employee Assistance Program
Notice of Employer's Drug Testing Policy:
Copy to all employees prior to testing iii Show notice of drug testing on vacancy
Posted on employer's premises announcements
Copy to Job applicants prior to testing a Copies available in personnel office or other
General notice given 60 days prior to testing suitable locations
❑ No notice required because the employer had a
drug testing program in place prior to July 1, 1990
Name of Medical Review Officer: Total Compliance Network - Dr. Seth Pnrtriny
954-341-255
A. Name of approved Agency for Health Care Administration Lab or United States Departen?of Health and
Human Services Certified Laboratory: Quest Diagnostics
B. Phone No.: ( 800) 877-7484
C. Address: 3175 Presidential Drive, Atlanta, GA 30340
Your certification Is subject to physical verification by the insurer. Your policy is subject to additional premium for
reimbursement of premium credit, and cancellation provisions of the policy if It is determined that you
misrepresented your compliance with Florida law. Any person who knowingly and with Intent to Injure, defraud, or
deceive any Insurer files a statement of claim or an application containing any false, incomplete, or misleading
information is guilty of a felony of the third degree.
Employer Nam l Cate
Application must be signed by an officer or owner.
TH ABOVE SIGNED CERTIFIES THAT THIS INFORMATION IS A TRUE AND FACTUAL DEPICTION OF
I" CURRENTi
wner Signature*
YP/ry'-G'
Title
NOV 2.00( / DFC., 200G
No ry Public's Signature Date
:' ►�Msr .- Raymond Beech
?* *? MY COMMISSION, 0. DDl6e237S EXPIRES
'-+-'TJ December 1, 2006
Rin d " BONDED THRU TROY FAIN INSURANCE, INC
Expiration of Commission
(NC3010)
Form 09-01 Revised 7/04
Copyright, 2004 National Council on Compensation Insurance, Inc.
UNIFORM WC 8093C (7.04)