Fill and Sign the Dfs F2 Dwc 49 Aggregate Claims Administration Change Report Form

AGGREGATE CLAIMS ADMINISTRATION CHANGE REPORT SENT TO DIVISION DATE DIVISION RECEIVED DATE FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION 200 East Gaines Street Tallahassee, FL 32399-4226 PLEASE PRINT OR TYPE CLAIMS-ADMINISTRATOR CHANGED FROM: CLAIMS-ADMINISTRATOR CHANGED TO: NAME OF SERVICING CO./TPA: __________________________________ ADDRESS: ____________________________________________________ ______________________________________________________ TELEPHONE: __________________________________________________ SERVICING CO./TPA CODE #: __ __________________________________ NAME OF INSURER, FUND, SELF-INSURED EMPLOYER: _________________________________________________ INSURER CODE #: ______________________________________________ NAME OF SERVICING CO./TPA: __________________________________ ADDRESS: ____________________________________________________ ______________________________________________________\ TELEPHONE: __________________________________________________ SERVICING CO./TPA CODE #: __ __________________________________ NAME OF INSURER, FUND, SELF-INSURED EMPLOYER: _________________________________________________ INSURER CODE #: ______________________________________________ EFFECTIVE DATE OF THE CHANGE IN CLAIMS ADMINISTRATION: _______________________________________________________________________ \ ALL DATES OF ACCIDENT DATE(S) OF ACCIDENT ON OR AFTER EFFECTIVE DATE THIS FORM IS DUE WITHIN 30 DAYS OF THE EFFECT IVE DATE OF THE CHANGE IN CLAIMS ADMINISTRATION SOCIAL SECURITY NUMBER EMPLOYEE NAME (First, Middle, Last) DATE OF ACCIDENT (Month-/Day/Year) EMPLOYER PLEASE ATTACH ADDITIONAL PAGE(S) OF THIS FORM IF NECESSARY, OR A LISTING IDENTICAL IN FORMAT (EMPLOYEE, SSN, D/A, EMPLOYER) INSURER NAME: CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE INSURER CODE # SERVICE CO./TPA CODE # Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-i nsured program, files a statement of claim containing any false or misleading information commits insurance fraud, punishable as provided in s. 817.234. Section 440.105(7), F.S. Form DFS-F2-DWC-49 (03/2009) Rule 69L-3.025, F.A.C. DWC-49 Purpose and Use Statement The collection of the social security number on this form is imperative for the Division of Workers' Compensation's performance of its duties and responsibilities as prescribed by law. The social security number will be used as a unique identifier in Division of Workers' Compensation database systems for individuals who have claimed benefits under Chapter 440, Florida Statutes. It will also be used to identify information and documents in those database systems regarding individuals who have claimed benefits under Chapter 440, Florida Statutes, for internal agency tracking purposes and for purposes of responding to both public records requests and subpoenas that require production of specified documents. The social security number may also be used for any other purpose specifically required or authorized by state or federal law.