ACORD 174 FL (2007/08)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 174 FL (2007/08)
Florida Revocation of Election of
Coverage
Use ACORD 174 FL, Florida Revocation of Election of Coverage, to notify the Florida
Division of Workers Compensation, Bureau of Compliance, that an individual who
previously submitted a notice of election of Workers' Compensation coverage now intends
to revoke the election.
ACORD 174 FL is the same as the Florida Division of Workers Compensation form DWC
251-R, revised June 2004.
REVOCATION
Limited Liability Company Member
Check this box if applicant is a member of a limited liability company.
Sole Proprietor
Check this box if applicant is a sole proprietor.
Partner
Check this box if applicant is a partner of a business.
BUSINESS ENTITY
Name of Business
Provide the name of the business.
BUSINESS ENTITY
Trade Name
Provide the trade name, DBA or AKA of the business (if applicable).
BUSINESS ENTITY
Business Mailing Address
Provide the business mailing address. Include apartment or suite number.
BUSINESS ENTITY
City
Provide the city of the organization.
BUSINESS ENTITY
County
Provide the county of the organization.
BUSINESS ENTITY
State
Provide the state of the organization.
BUSINESS ENTITY
Zip Code
Provide the zip code of the organization.
BUSINESS ENTITY
Federal Employer Identification
Number
Provide the federal employer identification number of the organization.
BUSINESS ENTITY
UI Number
Provide the Florida Employer Unemployment Compensation (UI) Number of the
organization.
BUSINESS ENTITY
Telephone Number
Provide the telephone number of the organization. (Include area code and number)
WORKERS'
COMPENSATION
INSURANCE PROVIDER
Name of Insurer
Indicate the name of the carrier currently providing Workers' Compensation coverage.
WORKERS'
COMPENSATION
INSURANCE PROVIDER
Address of Insurer
Indicate the address of the carrier currently providing Workers' Compensation coverage.
WORKERS'
COMPENSATION
INSURANCE PROVIDER
Policy Number
The number assigned by the carrier for the policy.
WORKERS'
COMPENSATION
INSURANCE PROVIDER
Effective Date of Policy
Provide the effective date of the policy.
APPLICANT(S)
Name
Provide the name of the applicant.
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Section Name
Field Name
Field and/or Section Description
APPLICANT(S)
Social Security Number
Provide the social security number of the applicant.
APPLICANT(S)
Signature
Applicant must sign the form.
APPLICANT(S)
Date
Date the form was signed.
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