AGGREGATE CLAIMS ADMINISTRATION CHANGE REPORT SENT TO DIVISION DATE DIVISION RECEIVED DATE FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION 200 East Gaines Street Tallahassee, FL 32399-4226 PLEASE PRINT OR TYPE CLAIMS-ADMINISTRATOR CHANGED FROM: NAME OF SERVICING CO./TPA: CLAIMS-ADMINISTRATOR CHANGED TO: __________________________________ NAME OF SERVICING CO./TPA: __________________________________ ADDRESS: ____________________________________________________ ______________________________________________________ ADDRESS: ____________________________________________________ ______________________________________________________ TELEPHONE: __________________________________________________ TELEPHONE: __________________________________________________ SERVICING CO./TPA CODE #: ____________________________________ SERVICING CO./TPA CODE #: ____________________________________ NAME OF INSURER, FUND, SELF-INSURED EMPLOYER: _________________________________________________ NAME OF INSURER, FUND, SELF-INSURED EMPLOYER: _________________________________________________ INSURER CODE #: ______________________________________________ INSURER CODE #: ______________________________________________ EFFECTIVE DATE OF THE CHANGE IN CLAIMS ADMINISTRATION: _______________________________________________________________________ ALL DATES OF ACCIDENT DATE(S) OF ACCIDENT ON OR AFTER EFFECTIVE DATE THIS FORM IS DUE WITHIN 30 DAYS OF THE EFFECTIVE DATE OF THE CHANGE IN CLAIMS ADMINISTRATION SOCIAL SECURITY NUMBER EMPLOYEE NAME (First, Middle, Last) DATE OF ACCIDENT (Month-/Day/Year) EMPLOYER INSURER NAME: PLEASE ATTACH ADDITIONAL PAGE(S) OF THIS FORM IF NECESSARY, OR A LISTING IDENTICAL IN FORMAT (EMPLOYEE, SSN, D/A, EMPLOYER) INSURER CODE # CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE SERVICE CO./TPA CODE # Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information commits insurance fraud, punishable as provided in s. 817.234. Section 440.105(7), F.S. Form DFS-F2-DWC-49 (03/2009) Rule 69L-3.025, F.A.C. American LegalNet, Inc. www.FormsWorkflow.com DWC-49 Purpose and Use Statement The collection of the social security number on this form is imperative for the Division of Workers' Compensation's performance of its duties and responsibilities as prescribed by law. The social security number will be used as a unique identifier in Division of Workers' Compensation database systems for individuals who have claimed benefits under Chapter 440, Florida Statutes. It will also be used to identify information and documents in those database systems regarding individuals who have claimed benefits under Chapter 440, Florida Statutes, for internal agency tracking purposes and for purposes of responding to both public records requests and subpoenas that require production of specified documents. The social security number may also be used for any other purpose specifically required or authorized by state or federal law. American LegalNet, Inc. www.FormsWorkflow.com