Workers Compensation and Employee Leasing of Florida

Please fill in the below information to request a certificate of insurance from Matrix Employee Leasing, Inc.

Matrix Client Name (your company name)
Certificate Holder (the name of the company you are working for)
Certificate Holder address
City, State, Zip
Certificate Holder phone number
Certificate Holder fax number
Job Name
Attn:
Does the Certificate Holder require a Waiver of Subrogation?	Yes No
Type of Certificate:
Additional comments