Workers' Compensation Liability Statement
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1
2
3INSTRUCTIONS FOR COMPLETING BOARD OF EMPLOYEE LEASING COMPANIES WORKERS’
COMPENSATION LIABILITY STATEMENT
Application begins on page 2
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
If applicable, pursuant to Rule 61G7-10.0012, Florida Administrative Code, please have this form signed
by the Chief Executive Officer and Chief Financial Officer of your Employee Leasing Company(s).
Complete all information in section (1) or section (2), whichever is applicable to your company,
and return the form along with your Annual Report to the address listed below.
Transaction
Requirements
Complete DBPR EL-4516 – Workers’ Compensation Liability
Statement
Report Submission
Submit a copy of the latest Annual Report
Please send your completed application, documentation and required fee(s) to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, FL 32399-0783
DBPR EL-4516
Page 1 of 3
Employee Leasing: Worker's Compensation Liability Statement
Effective Date 5/2011
Rule: 61G7-10.0012
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