Free DWC 251-R - Florida

STATE USE ONLY

REVOCATION OF ELECTION OF COVERAGE
By filing this Revocation, you elect to be exempt from the provisions of Chapter 440, Florida Statutes, and WAIVE ANY RIGHT YOU MAY HAVE to workers' compensation benefits in the State of Florida should you become injured on the job.

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

Sole Proprietor Partner
Business Entity
Name of Business:

PLEASE TYPE OR PRINT

Trade Name; d/b/a; or a/k/a:

Business Mailing Address:

City:

County:

State:

Zip Code:

Federal Employer Identification Number:

UI Number:

Telephone Number:

Workers' Compensation Insurance Provider
Name of Insurer:

Address of Insurer: Policy Number: Effective Date of Policy:

Applicant (s)
Name:____________________________________________ Date:_____________________

STATE USE ONLY
Effective/Issue Date:

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-R, REVOCATION OF ELECTION OF COVERAGE - REVISED 12/08; RULE 69L-6.009, F.A.C.