Form DFS-F2-DWC 251-R "Revocation of Election of Coverage" - Florida

Form DFS-F2-DWC 251-R or the "Revocation Of Election Of Coverage" is a form issued by the Florida Department of Financial Services.

Download a PDF version of the Form DFS-F2-DWC 251-R down below or find it on the Florida Department of Financial Services Forms website.

ADVERTISEMENT

Download Form DFS-F2-DWC 251-R "Revocation of Election of Coverage" - Florida

1173 times
Rate
(4.8 / 5) 70 votes
REVOCATION OF ELECTION OF COVERAGE
By filing this Revocation, you are revoking a previously filed Notice of Election of Coverage.
(Check one):
Sole Proprietor
Partner
PLEASE TYPE OR PRINT
Business Entity
Name of Business:
Trade Name; d/b/a; or a/k/a:
Business Mailing Address:
City:
County:
State:
Zip Code:
Federal Employer Identification Number:
Telephone Number:
Email:
Workers’ Compensation Insurance Provider
Name of Insurer:
Address of Insurer:
Policy Number:
Effective Date of Policy:
Applicant
Name:____________________________________________
Date:____________________
Signature:____________________________________________________________________
SUBMIT THIS FORM TO:
DIVISION OF WORKERS’ COMPENSATION
BUREAU OF COMPLIANCE
200 East Gaines Street
Tallahassee, FL 32399-4228
DFS-F2-DWC 251-R, REVOCATION OF ELECTION OF COVERAGE - REVISED 08/13
MS 10-16
REVOCATION OF ELECTION OF COVERAGE
By filing this Revocation, you are revoking a previously filed Notice of Election of Coverage.
(Check one):
Sole Proprietor
Partner
PLEASE TYPE OR PRINT
Business Entity
Name of Business:
Trade Name; d/b/a; or a/k/a:
Business Mailing Address:
City:
County:
State:
Zip Code:
Federal Employer Identification Number:
Telephone Number:
Email:
Workers’ Compensation Insurance Provider
Name of Insurer:
Address of Insurer:
Policy Number:
Effective Date of Policy:
Applicant
Name:____________________________________________
Date:____________________
Signature:____________________________________________________________________
SUBMIT THIS FORM TO:
DIVISION OF WORKERS’ COMPENSATION
BUREAU OF COMPLIANCE
200 East Gaines Street
Tallahassee, FL 32399-4228
DFS-F2-DWC 251-R, REVOCATION OF ELECTION OF COVERAGE - REVISED 08/13
MS 10-16
ADVERTISEMENT