COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .STATE USE ONLY Effective/Issue Date::::::::Index No.REVOCATION OF ELECTION OF COVERAGECalendar No.Control Number: Postmark Date: Received Date:By filing this Revocation, you elect to be exempt from the provisions of Chapter 440, Florida Statutes, and WAIVE ANY RIGHT YOU MAY HAVE to workers' compensation benefits in the State of Florida should you become injured on the job.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Limited Liability Company Member Sole Proprietor PartnerBusiness 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:Name:Social Security #:Attorney(s) forSignature: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-R -Revised June 2004Telephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com
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