Les Form Bcm-251-R - Revocation Of Election Of Coverage

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STATE USE ONLY
Effective/Issue Date:
REVOCATION OF ELECTION OF COVERAGE
__________________________________
By filing this revocation, you elect to be exempt from the provisions of Chapter 440,
Control Number:
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.
__________________________________
Postmark Date:
Sole Proprietor
__________________________________
Partner
Received Date:
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-R
Revised February 2000

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