Form PR-PML-120 "Worker's Compensation Insurance Verification" - California

What Is Form PR-PML-120?

This is a legal form that was released by the California Department of Pesticide Regulation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2004;
  • The latest edition provided by the California Department of Pesticide Regulation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form PR-PML-120 by clicking the link below or browse more documents and templates provided by the California Department of Pesticide Regulation.

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Download Form PR-PML-120 "Worker's Compensation Insurance Verification" - California

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STATE OF CALIFORNIA
DEPARTMENT OF PESTICIDE REGULATION
PEST MANAGEMENT AND LICENSING BRANCH
WORKER'S COMPENSATION INSURANCE VERIFICATION
LICENSING AND CERTIFICATION PROGRAM
PR-PML-120 (REV. 12/04)
1001 I STREET
SACRAMENTO, CALIFORNIA 95814-2828
(916) 445-4038
FAX - (916) 445-4033
Web site: http://www.cdpr.ca.gov/
A. Declaration. Please print or type.
I,
, the undersigned, verify under penalty of perjury, under laws of the State of
Name
California, that the information provided below, is true and correct. The business mentioned herein is covered by worker's
compensation insurance:
Name of Business
License number:
.
Telephone number: (
)
.
B. Worker's Compensation Insurance Information. Please print or type.
Worker's Compensation Insurance Carrier Name
Policy Number
Expiration Date
Telephone Number
Email Address
(
)
C. Sign and Mail. Sign, date and complete the address information listed below. Mail to: Pest Management and Licensing,
Licensing and Certification Program, Department of Pesticide Regulation, P.O. Box 4015, Sacramento, California 95812-4015.
Signature
Date
Title
Address
City, State
Zip Code
STATE OF CALIFORNIA
DEPARTMENT OF PESTICIDE REGULATION
PEST MANAGEMENT AND LICENSING BRANCH
WORKER'S COMPENSATION INSURANCE VERIFICATION
LICENSING AND CERTIFICATION PROGRAM
PR-PML-120 (REV. 12/04)
1001 I STREET
SACRAMENTO, CALIFORNIA 95814-2828
(916) 445-4038
FAX - (916) 445-4033
Web site: http://www.cdpr.ca.gov/
A. Declaration. Please print or type.
I,
, the undersigned, verify under penalty of perjury, under laws of the State of
Name
California, that the information provided below, is true and correct. The business mentioned herein is covered by worker's
compensation insurance:
Name of Business
License number:
.
Telephone number: (
)
.
B. Worker's Compensation Insurance Information. Please print or type.
Worker's Compensation Insurance Carrier Name
Policy Number
Expiration Date
Telephone Number
Email Address
(
)
C. Sign and Mail. Sign, date and complete the address information listed below. Mail to: Pest Management and Licensing,
Licensing and Certification Program, Department of Pesticide Regulation, P.O. Box 4015, Sacramento, California 95812-4015.
Signature
Date
Title
Address
City, State
Zip Code