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 ...

DEPARTMENT OF FINANCIAL SERVICES
Division of Worker's Compensation

RULE NO: RULE TITLE
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, [phone]

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:

 

921 North Davis Street, Building B	1111 N. E. 25th Avenue, Suite 403
Suite 250	Ocala, FL 34470
Jacksonville, FL 32209	Telephone [phone]
Telephone [phone]
2012 Capital Circle, S. E.	3111 South Dixie Highway
Suite 106102, Hartman Bldg.	Suite 123
Tallahassee, FL 32399-2161	West Palm Beach, FL 33405
Telephone [phone]	Telephone [phone]
610 East Burgess Road	4415 Metro Parkway
Pensacola, FL 32504-6320	Suite #300
Telephone [phone]	Ft. Myers, FL 33916
	Telephone [phone]
499 N.W. 70th Avenue	Live Oak Business Center
Suite 116	5969 Cattlemen Lane
Plantation, FL 33317	Sarasota, FL 34232
Telephone [phone]	Telephone [phone]
1313 North Tampa Street	401 N.W. 2nd Avenue
Suite 503	South Tower, Suite 321
Tampa, FL 33602	Miami, FL 33128
Telephone [phone]	Telephone [phone]
400 West Robinson Street
Suite N 512, North Tower
Orlando, FL 32801
Telephone [phone] or [phone]

 

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,________.