simpliCity - Vendor Registration Page

If your organization desires to signup for the Emergency Vendor Registration Program, please fill out the form below. Once you submit the information, you will be taken to a payment page. Participation in this program is voluntary. More information about the program can be found by clicking here.

If your company has already filled out this form, please direct updates to information to our support staff.

FMIT Qualified Vendor Program Registration Form:

Company Information:
Company Name
Address1
Address2
City
State		Zip
Website
Enrollment Level
General Company Information:
Year Incorporated
Annual Revenue
Number of Employees
Bond Capacity	(Enter number)
Professional Liability Insurance
Service Category Selections:
Service Category 1
Service Category 2
Service Category 3
Description of Services:
Primary Contact Information:
Primary Contact
Title
Office Phone
Cell Phone
Email
Accounting Contact Information:
Accounting Contact Name
Office Phone
Office Fax
Address1
Address2
City
State		Zip
Company Business Information:
Tax ID (EIN or SSN)
W-9 Attachment
Florida Certification (Registration)
FL County Certificate of Competency
FL County Occupational License
Insurance Certificate*
	* Please include a copy of your declarations page provided by your insurance carrier. The required insurance certificate must be issued by an insurance company that is properly licensed, duly authorized business in the State of Florida or another state, and meets minimum qualifications based on the most current edition of A.M. Best’s Insurance Guide.
Workers Comp. Certification
By clicking the "Submit" button below, you are authorizing Synergy ID LLC to review your information and submit it into simpliCity software for access by Members of the Florida Municipal Insurance Trust.