Update Existing Qualifying Agent Information
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
*
To find your existing AEC Number, follow these steps:
Log in to
eTRAKIT
and select VIEW/EDIT PROFILE.
The number displayed above your email address is your AEC number.
Your AEC Number
*
Business Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Business Email
*
example@example.com
This section is to ADD a qualifier on the existing account registration
The update and remove qualifier sections are below.
Qualifying Agent Information. Add as many rows as you need.
*
Qualifying Agent Florida State License and BCAIB Licenses for DAR's
Browse Files
Drag and drop files here
Choose a file
Upload Licenses
Cancel
of
General Liability Insurance Information
Browse Files
Drag and drop files here
Choose a file
Upload Certificate of Insurance
Cancel
of
Qualifying Agent Florida State License and BCAIB Licenses for DAR's
Browse Files
Drag and drop files here
Choose a file
Upload Licenses
Cancel
of
This section is to UPDATE a qualifier on the existing account registration
The remove qualifier section is below.
Upload Workman's Compensation & Liability Insurance
Browse Files
Drag and drop files here
Choose a file
Upload Certificate of Insurance
Cancel
of
General Liability Insurance Information
Browse Files
Drag and drop files here
Choose a file
Upload Certificate of Insurance
Cancel
of
Upload Workman's Compensation & Liability Insurance
Browse Files
Drag and drop files here
Choose a file
Upload Certificate of Insurance
Cancel
of
This section is to REMOVE a qualifier on the existing account registration
Qualifying Agent Information. Add as many rows as you need.
*
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 Name
Last Name
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