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

What Is Form DFS-F2-DWC 251-R?

This is a legal form that was released by the Florida Department of Financial Services - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2013;
  • The latest edition provided by the Florida Department of Financial Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form DFS-F2-DWC 251-R by clicking the link below or browse more documents and templates provided by the Florida Department of Financial Services.

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

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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