Les Form Bcm-251 - Notice Of Election Of Coverage
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1STATE 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 non-
__________________________________
construction industry (check one):
Postmark Date:
__________________________________
Sole Proprietor
Received Date:
Partner
Business Entity
PLEASE TYPE OR PRINT
Name of Business:
Trade Name; d/b/a; or a/k/a:
Business Mailing Address:
City:
County:
State:
Zip Code:
Federal Employer Identification Number:
UI Number:
Telephone Number:
Workers’ Compensation Insurance Provider
Name of Insurer:
Address of Insurer:
Policy Number:
Effective Date of Policy:
STATE USE ONLY
Applicant (s)
Effective/Issue
Name:____________________________________________
Social Security #:_____________________
Date:
Signature:_________________________________________
Date:_______________________________
Effective/Issue
Name:____________________________________________
Social Security #:_____________________
Date:
Signature:_________________________________________
Date:_______________________________
Effective/Issue
Name:____________________________________________
Social Security #:_____________________
Date:
Signature:_________________________________________
Date:_______________________________
SUBMIT THIS FORM TO:
DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY
DIVISION OF WORKERS’ COMPENSATION-BUREAU OF COMPLIANCE
2562 Executive Center Circle East
Montgomery Building, Suite 107
Tallahassee, Fl. 32399-0661
LES FORM BCM-251 Revised February 2000
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