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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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Ofand that I have is a form used to report financial information.
Individuals or entities with financial assets or income may be required to file ofand that I have.
Ofand that I have can be filled out online or submitted in paper form with all required financial information.
The purpose of ofand that I have is to inform the relevant authorities about an individual's or entity's financial status.
Information such as income, assets, and liabilities must be reported on ofand that I have.
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