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You are here: Home . bulletins . 1998 . b0073-8c

Workers' Compensation Revised Relativities

Notice of Carrier Intent - Certification Page 3

Notice of Carrier Intent Certification

I, ________________________________, am an officer of the ____________________________________ and in that capacity, I certify that all of the information contained in the Notice of Carrier Intent is complete, correct, and true to the best of my knowledge and belief.

_____________________________________

Officer´s Signature

_____________________________________

Officer´s Title

Attachment 4



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Last updated: 01/04/2018

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