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 ...  


  • 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, (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:

     

    921 North Davis Street, Building B

    1111 N. E. 25th Avenue, Suite 403

    Suite 250

    Ocala, FL 34470

    Jacksonville, FL 32209

    Telephone (352)401-5350

    Telephone (904) 798-5806

     

     

     

    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 (850)413-1609

    Telephone (561)837-5716

     

     

    610 East Burgess Road

    4415 Metro Parkway

    Pensacola, FL 32504-6320

    Suite #300

    Telephone (850)453-7804

    Ft. Myers, FL 33916

     

    Telephone (239) 938-1840

     

     

    499 N.W. 70th Avenue

    Live Oak Business Center

    Suite 116

    5969 Cattlemen Lane

    Plantation, FL 33317

    Sarasota, FL 34232

    Telephone (954)321-2906

    Telephone (941)329-1120

     

     

    1313 North Tampa Street

    401 N.W. 2nd Avenue

    Suite 503

    South Tower, Suite 321

    Tampa, FL 33602

    Miami, FL 33128

    Telephone (813)221-6506

    Telephone (305)536-0306

     

     

    400 West Robinson Street

     

    Suite N 512, North Tower

     

    Orlando, FL 32801

     

    Telephone (407)835-4406 or (407)245-0896

     

     

    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,________.