Notice Of Election Of Coverage
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Notice Of Election Of Coverage Form. This is a Florida form and can be use in Workers Comp.
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Tags: Notice Of Election Of Coverage, DWC-251, Florida Workers Comp,
STATE USE ONLY
Effective/Issue Date:
NOTICE OF ELECTION OF COVERAGE
__________________________________
Control Number:
The applicant (s) herein elect to be included in the definition of employee, eligible for
workers’ compensation benefits pursuant to Chapter 440, Florida Statues as a nonconstruction industry (check one):
__________________________________
Received Date:
Sole Proprietor
Partner
Business Entity
__________________________________
Postmark Date:
PLEASE TYPE OR PRINT
Name of Business:
Trade Name; d/b/a; or a/k/a:
Business Mailing Address:
City:
County:
State:
Federal Employer Identification Number:
UI Number:
Zip Code:
Telephone Number:
Workers’ Compensation Insurance Provider
Name of Insurer:
Address of Insurer:
Policy Number:
Effective Date of Policy:
Applicant (s)
STATE USE ONLY
Effective/Issue Date:
Name:____________________________________________
Date:____________________
Signature:____________________________________________________________________
Effective/Issue Date:
Name:____________________________________________
Date:____________________
Signature:____________________________________________________________________
Effective/Issue Date:
Name:____________________________________________
Date:____________________
Signature:____________________________________________________________________
SUBMIT THIS FORM TO:
DIVISION OF WORKERS’ COMPENSATION
BUREAU OF COMPLIANCE
200 East Gaines Street
Tallahassee, FL 32399-4228
DWC 251, NOTICE OF ELECTION OF COVERAGE - REVISED 12/08; RULE 69L-6.009, F.A.C.
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