Form Dwc-49 - Aggregate Claims Administration Change Report 1994

SENT TO DIVISION DATE

AGGREGATE CLAIMS ADMINISTRATION CHANGE REPORT

FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY

DIVISION OF WORKERS' COMPENSATION

2728 Centerview Drive, 202 Forrest Building

Tallahassee, FL 32399-0685

PLEASE PRINT OR TYPE

CLAIMS ADMINISTRATOR CHANGED FROM:

CLAIMS ADMINISTRATOR CHANGED TO:

NAME OF SERVICING CO./TPA: ____________________________________

NAME OF SERVICING CO./TPA: ____________________________________

ADDRESS: ______________________________________________________

ADDRESS: ______________________________________________________

______________________________________________________

______________________________________________________

TELEPHONE: ____________________________________________________

TELEPHONE: ____________________________________________________

SERVICING CO./TPA CODE #: ______________________________________

SERVICING CO./TPA CODE #: ______________________________________

NAME OF CARRIER, FUND, SELF-INSURED EMPLOYER:

NAME OF CARRIER, FUND, SELF-INSURED EMPLOYER:

____________________________________________________

___________________________________________________

CARRIER CODE #: _______________________________________________

CARRIER CODE #: _______________________________________________

EFFECTIVE DATE OF THE CHANGE IN CLAIMS ADMINISTRATION: _________________________________________________________________________

ALL DATES OF ACCIDENT

DATE(S) OF ACCIDENT ON OR AFTER EFFECTIVE DATE

THIS FORM IS DUE WITHIN 30 DAYS OF THE EFFECTIVE DATE OF THE CHANGE IN CLAIMS ADMINISTRATION

EMPLOYEE NAME

SOCIAL SECURITY NUMBER

DATE OF ACCIDENT

EMPLOYER

CARRIER NAME, ADDRESS & TELEPHONE

PLEASE ATTACH ADDITIONAL PAGE(S) OF THIS FORM IF NECESSARY,

OR A LISTING IDENTICAL IN FORMAT (EMPLOYEE, SSN, D/A, EMPLOYER)

CARRIER CODE #

SERVICE CO./TPA CODE #

Any person who, knowingly and with intent to injure, defraud or deceive any employer or employee, insurance company or self-insured program, files a statement of claim containing any false or

misleading information is guilty of a felony of the third degree.

LES Form DWC-49 (11/94)