69L-6.009: Forms and Instructions
PURPOSE AND EFFECT: To revise the following forms to comply with Section 119.071(5), F.S. (2007), that precludes an agency from requesting an individual’s social security number unless such collection conforms to the specified provisions of that statute. The following forms are revised: Form DWC 250 (Notice of Election to be Exempt), is amended to include a purpose and use statement regarding the collection of the social security number; Form DWC 250-R (Notice of Revocation of Election to be Exempt), DWC 251 (Notice of Election of Coverage), and DWC 251-R (Revocation of Election of Coverage), are amended so that the collection of the social security number is discontinued. This amendment also makes a clerical revision to the existing rule relating to a field office address.
SUBJECT AREA TO BE ADDRESSED: Revision of Forms.
SPECIFIC AUTHORITY: 440.05(9), 440.591 FS.
LAW IMPLEMENTED: 440.05 FS.
IF REQUESTED IN WRITING AND NOT DEEMED UNNECESSARY BY THE AGENCY HEAD, A RULE DEVELOPMENT WORKSHOP WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:
TIME AND DATE: Tuesday, August 5, 2008, 10:00 a.m.
PLACE: 104J, Hartman Bldg., 2012 Capital Circle S.E., Tallahassee, Florida
Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 5 days before the workshop/meeting by contacting: Tasha Carter. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT, IF AVAILABLE, IS: Tasha Carter, Bureau Chief, Bureau of Compliance, Division of Workers’ Compensation, Department of Financial Services, 200 East Gaines Street, Tallahassee, Florida 32399-4228, (850)413-1878
THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:
69L-6.009 Forms and Instructions.
(1) The following forms are hereby adopted for use in connection with these rules:
(a) DWC 250 Notice of Election to be Exempt, (eff. _______1/08); and instructions for same (Instructions for Completing Notice of Election to be Exempt, (eff. _______1/08).
(b) DWC 250-R Revocation of Election to be Exempt, eff. _______revised 2/00.
(c) DWC 251 Notice of Election of Coverage, eff. _______revised 2/00.
(d) DWC 251-R Revocation of Election of Coverage, eff. _______revised2/00.
(e) DWC 252, Certificate of Election to be Exempt, (eff. 1/08).
(2) The forms may be obtained from the Bureau of Compliance, Division of Workers’ Compensation website at: www.fldfs.com/WC/ or from any field office, unless otherwise limited to direct issuance by the Division.
(3) The field offices of the Division of Workers’ Compensation, Bureau of Compliance, are:
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921 North Davis Street, Building B |
1111 N. E. 25th Avenue, Suite 403 |
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Suite 250 |
Ocala, FL 34470 |
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Jacksonville, FL 32209 |
Telephone (352)401-5350 |
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Telephone (904) 798-5806 |
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2012 Capital Circle, S. E. |
3111 South Dixie Highway |
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Suite 106 |
Suite 123 |
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Tallahassee, FL 32399-2161 |
West Palm Beach, FL 33405 |
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Telephone (850)413-1609 |
Telephone (561)837-5716 |
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610 East Burgess Road |
4415 Metro Parkway |
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Pensacola, FL 32504-6320 |
Suite #300 |
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Telephone (850)453-7804 |
Ft. Myers, FL 33916 |
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Telephone (239) 938-1840 |
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499 N.W. 70th Avenue |
Live Oak Business Center |
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Suite 116 |
5969 Cattlemen Lane |
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Plantation, FL 33317 |
Sarasota, FL 34232 |
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Telephone (954)321-2906 |
Telephone (941)329-1120 |
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1313 North Tampa Street |
401 N.W. 2nd Avenue |
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Suite 503 |
South Tower, Suite 321 |
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Tampa, FL 33602 |
Miami, FL 33128 |
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Telephone (813)221-6506 |
Telephone (305)536-0306 |
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400 West Robinson Street |
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Suite N 512, North Tower |
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Orlando, FL 32801 |
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Telephone (407)835-4406 or (407)245-0896 |
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Specific Authority 440.05(9), 440.591 FS. Law Implemented 440.05 FS. History–New 11-20-79, Amended 4-15-81, 1-2-86, Formerly 38F-6.09, Amended 5-28-91, 2-15-94, 2-2-00, 3-5-02, Formerly 38F-6.009, 4L-6.009, Amended 2-19-07, 1-7-08,________.