dy signed into Employee Access, you don't need to sign in again! Important: Access is provided if your employer purchased a health policy through Automatic Data Processing Insurance Agency, Inc. If you are a new hire or it's an open enrollment period, you'll see an open enrollment countdown with a link to enroll today. The options

) 3/12/2019 5:27.50 PM FLORIDA WORKERS COMPENSATION APPLICATION DATE eamtnemern 3/12/2019 PRODUCER PHONE (NC No COY FAX UM. NM 855457-0101 Automatic Data Processing Insurance Agency, Inc. 1 ADP Blvd. Roseland, NJ, 07068 COMPANY AmTrust Insurance Company of Kansas, Inc. APPLICANT NAME • INCLUDE ALL suesioureas DBAW TO BE INCU

III1111111111l r. EFTA00523631 I X11111 hIIII VIII VIII VIII VIII VIII VIII IIII111111IIIII VIII VIII IIII VIII HlhhIII H Ill! 00109547 70 - Automatic Data Processing Insurance Agency. Inc. Page 12 Workers' Compensation Loss History Affidavit X (name of owner or officer) has incurred X (Number of Injuries) , do hereby certif