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PLEASE TYPE OR PRINT LEGIBLY. State Form 12386SELFINSURED EMPLOYER CERTIFICATIONSTATE COUNTY OF, hereby CERTIFY that I am(Official Title)of and that I have knowledge of the(Company)workers compensation
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I hereby certify that is a statement confirming the truthfulness of the information being provided.
Individuals or entities who are providing information that needs to be verified may be required to file i hereby certify that.
To fill out i hereby certify that, one must provide the required information and sign the statement to confirm its accuracy.
The purpose of i hereby certify that is to ensure the accuracy and truthfulness of the information being provided.
The information that must be reported on i hereby certify that will vary depending on the specific situation or document being verified.
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