Free UCS-6A - Florida

Employer's Reciprocal Coverage Election Supplemental Attachment

UCS-6A R. 07/07

This form must be attached to each copy of the Employer's Reciprocal Coverage Election (UCS-6). 1. The jurisdictions listed below are hereby included in Item 1 of the election to which this sheet is attached: STATE % OF SERVICE STATE % OF SERVICE

2. The employees listed below are hereby included in Item 2 of the election to which this sheet is attached: SOCIAl SECURITy NUmbER EmplOyEE'S lEGAl RESIDENCE bASIS FOR ElECTION IN FlORIDA a) Does some work in Florida b) Residence in Florida c) Related to a place of business in Florida

EmplOyEE'S NAmE

____________________________ Date

_________________________________________________________________ Firm ­ Name of Employer

www.myflorida.com/dor