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2. License Holder Name*
4. Company Name*
6. Business Phone #*
7. Business Fax #
9. Mailing Address*
11. City*
12. State*
13. Zip*
15. State Certified Number*
16. Driver License Number - Qualifier*
18. Email Address*
19. Federal Identification Number*
21. Please submit the following:
23. Copy of State Certified License*
24. Copy of Qualifiers Drivers License*
26. Workers Compensation exemption form (if applicable) from the Department of Financial Services
28. Certificate of Insurance - Liability and Workers Compensation:
    --General & Building: $300,000 Bodily Injury; $50,000 Property Damage
    --Electrical: $300,000 per occurrence; $500,000 Property Damage
    --All other categories: $100,000 Bodily Injury; $25,000 Property Damage
30. Certificates of Insurance

    • Must be emailed to the Building Department, faxed (352-689-4401), or mailed directly from the insurance company and must be valid in Florida. The company name being registered should be listed in the subject line of the email or fax.

    • Insurance Certificates and Workers Compensation Exemption Forms must appear in the exact name as your DBPR License or your Sumter County Competency Card. 

32. Sumter County Building Department must be listed as the certificate holder with the address of:

    7375 Powell Road, Suite 115
    Wildwood, FL 34785

    Phone: 352-689-4400
    Fax: 352-689-4401
    Email the Building Department

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33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field