Form Bcm 242 - Notice Of Cancellation Of Reinstatement printable pdf download

Form Bcm 242 - Notice Of Cancellation Of Reinstatement

STATE USE ONLY

NOTICE OF CANCELLATION OR REINSTATEMENT

Effective Date: _______________________

SUBMIT THIS FORM TO:

Department of Labor and Employment Security

Control Number: _____________________

Division of Workers’ Compensation-Bureau of Compliance

Postmark Date: ______________________

2562 Executive Center Circle East

Montgomery Building, Suite 107

Received Date: _______________________

Tallahassee, Fl. 32399-0661

CARRIER USE ONLY

Issue Date: _____________

Date Employer Notified: _____________________

Carrier/Insurer Code Number: _________________

POLICY INFORMATION

Insured Fein:

Carrier/Insurer Fein:

Insured Name:

Carrier/Insurer Name:

Insured Address:

Carrier/Insurer Address:

Policy Number:

Policy Effective Date:

Prior Policy ID:

Prior Policy Effective Date:

CANCELLATION

Notice is hereby given in accordance with the provision of Section 440.42, Florida Statutes, that coverage

is being cancelled as of __________________12:01 a.m. for the following reason(s):

Business Sold

Misrepresentation of information on application

Change in Ownership

No Employees/Exposure/Operations

Coverage placed elsewhere

Non-payment

Deleting jurisdiction

Out of Business

Duplicate coverage

Revocation of Voluntary Market

Failure to pay deductible

Rewritten/Reissued

Flat Termination (notice filed prior to effective

Underwriting reasons

date of policy)

Original Cancellation Date:

Revised Cancellation Date:

REINSTATEMENT

The coverage provided by the policy number shown above and previously cancelled or scheduled for

cancellation on _____________________ is being reinstated effective 12:01 a.m. ___________________.

Lapse in Coverage

Yes

LES FORM BCM 242

Revised February 2000

Form Bcm 242 - Notice Of Cancellation Of Reinstatement

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