Les Form Bcm 241 - Endorsement - Florida printable pdf download

Les Form Bcm 241 - Endorsement - Florida

STATE USE ONLY

ENDORSEMENT

Effective Date: _____________________

Control Number: ___________________

SUBMIT THIS FORM TO:

Department of Labor and Employment Security

Postmark Date: ____________________

Division of Workers’ Compensation-Bureau of Compliance

2562 Executive Center Circle East

Received Date: ____________________

Montgomery Building, Suite 107

Tallahassee, Fl. 32399-0661

INSURER INFORMATION

Carrier/Insurer Name:

Carrier/Insurer Code:

Carrier/Insurer FEIN:

Carrier/Insurer Code:

Carrier/Insurer FEIN:

CARRIER/INSURER NAME CHANGE TO:

POLICY INFORMATION

Policy ID:

Policy Effective Date:

Prior Policy I.D. :

Effective Date of Change:

Issue Date:

POLICY ID CHANGE TO:

INSURED INFORMATION

ADD

CHANGE

DELETE

EFFECTIVE DATE:

( IF NAME CHANGE SHOW OLD NAME ON LEFT & NEW NAME ON RIGHT)

Insured Name:

Insured FEIN/SSN:

Insured Mailing Address:

Insured Location Address:

UI Number:

SIC:

# Employees:

UI Number:

SIC:

# Employees:

EMPLOYER INFORMATION

ADD

CHANGE

DELETE

EFFECTIVE DATE:

(IF NAME CHANGE SHOW OLD NAME ON LEFT & NEW NAME ON RIGHT)

Employer Name: ( D/B/A, T/A, A/K/A )

Employer FEIN/SSN:

Employer Mailing Address:

Employer Location Address:

UI Number:

SIC:

# Employees:

UI Number:

SIC:

# Employees:

If there are additional locations that cannot be listed above, complete the endorsement attachment sheet

( LES Form BCM- 241-A ). Number of additional pages attached _________________ .

LES FORM BCM 241

Revised February 2000

Les Form Bcm 241 - Endorsement - Florida

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