Revocation Of Election Of Coverage
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Revocation Of Election Of Coverage Form. This is a Florida form and can be use in Workers Comp.
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Tags: Revocation Of Election Of Coverage, DWC-251-R, Florida Workers Comp,
STATE USE ONLY
REVOCATION OF ELECTION OF COVERAGE
By filing this Revocation, you elect to be exempt from the provisions of Chapter 440, Florida
Statutes, and WAIVE ANY RIGHT YOU MAY HAVE to workers’ compensation benefits in
the State of Florida should you become injured on the job.
Sole Proprietor
Partner
Business Entity
Effective/Issue Date:
__________________________________
Control Number:
__________________________________
Postmark Date:
__________________________________
Received 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-R, REVOCATION OF ELECTION OF COVERAGE - REVISED 12/08; RULE 69L-6.009, F.A.C.
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