Free DWC 251 - Florida

STATE USE ONLY

NOTICE OF ELECTION OF COVERAGE
The applicant (s) herein elect to be included in the definition of employee, eligible for workers' compensation benefits pursuant to Chapter 440, Florida Statues as a nonconstruction industry (check one):

Effective/Issue Date: __________________________________ Control Number: __________________________________ Postmark Date: __________________________________ Received Date:

Sole Proprietor Partner Business Entity
Name of Business: Trade Name; d/b/a; or a/k/a: Business Mailing Address: City: Federal Employer Identification Number: County: UI Number: State:

PLEASE TYPE OR PRINT

Zip Code:

Telephone Number:

Workers' Compensation Insurance Provider
Name of Insurer: Address of Insurer: Policy Number: Effective Date of Policy:

Applicant (s)

STATE USE ONLY Effective/Issue Date: Date:____________________

Name:____________________________________________

Signature:____________________________________________________________________ Effective/Issue Date: Name:____________________________________________ Date:____________________

Signature:____________________________________________________________________ Effective/Issue Date: Name:____________________________________________ Date:____________________

Signature:____________________________________________________________________

SUBMIT THIS FORM TO:
DIVISION OF WORKERS' COMPENSATION BUREAU OF COMPLIANCE 200 East Gaines Street Tallahassee, FL 32399-4228

DWC 251, NOTICE OF ELECTION OF COVERAGE - REVISED 12/08; RULE 69L-6.009, F.A.C.