Private Provider Firm Registration

Private Provider Firm Registration

You do not need to complete this form in one session. To save your progress and return later, use the Save button located at the bottom of the form.
Private Provider Legal Business Name
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Business Email
example@example.com
Qualifying Agent Information. Add as many rows as you need.
Qualifying Agent Florida State License and BCAIB Licenses for DAR's

Upload Licenses
Cancelof
General Liability Insurance Information

Upload Certificates of Insurance
Cancelof
Upload Workman's Compensation & Liability Insurance

Upload Certificates of Insurance
Cancelof
Insurance Company Name
Policy Number
Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Duly Authorized Personnel List. Add as many rows as you need.
The private provider or private provider firm must update its registration within 5 business days after any change to the provider’s or firm’s contact information, licensure, or insurance coverage.

Update Existing Qualifying Agent Information

Update Existing Duly Authorized Personnel Information

Contact Information

Rows	Contact Name	Contact Number	Contact Email
Primary
Emergency

Complete the Private Provider Acknowledgment and upload it.
Private Provider Acknowledgement

Upload Document
Cancelof
By typing my name in the below space, I am electronically signing this form. By signing this electronic signature certifies the information to be true, accurate, and complete.

First NameLast Name
Should be Empty: