COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .STATE USE ONLY Effective/Issue Date::::::::Index No.NOTICE OF ELECTION OF COVERAGECalendar No.Control Number: Postmark Date: Received Date:The applicant(s) herein elect to be included in the definition of employee and thereby become eligible for workers' compensation benefits pursuant to Chapter 440, Florida Statues, as a NON-CONSTRUCTION INDUSTRY (check one):JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Limited Liability Company Member Sole Proprietor Partner. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Business EntityPLEASE TYPE OR PRINT Name of Business:Trade Name; d/b/a; or a/k/a: Business Mailing Address: City:THE PEOPLE OF THE STATE OF NEW YORK TOCounty:State:Zip Code:Federal Employer Identification Number:UI Number:Telephone Number:GREETINGS:Workers' Compensation Insurance ProviderWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorableName of Insurer: Address of Insurer: Policy Number:,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomEffective Date of Policy:Applicant(s)STATE USE ONLYYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.Effective/Issue Date:Name:Social Security #:Signature:Date:, one of the Justices of theCourt in Witness, Honorableday of, 20 County,Effective/Issue Date:Name:Social Security #:(Attorney must sign above and type name below)Signature:Date:Effective/Issue Date:Attorney(s) forName:Social Security #:Signature:Date:Office and P.O. AddressSUBMIT THIS FORM TO: DIVISION OF WORKERS' COMPENSATION BUREAU OF COMPLIANCE 200 East Gaines Street Tallahassee, FL 32399-4228 DWC 251 Revised June 2004Telephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com
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