Florida Regulations 69L-6.007 79

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§ Compensation Notice.



(1) Upon issuance of an insurance policy or certificate of membership in a self-insurance fund or a renewal certificate thereof, the insurer or self-insurance servicing agent shall furnish the employer a sufficient number of typewritten or printed compensation notices, commonly referred to as the "broken arm poster." The compensation notice shall be printed on paper or cardboard stock 11 inches by 17 inches, and have the same form and content as Form DI4-1548" Workers' Comp Works For You Poster", (Rev 12/02), which is incorporated herein by reference. As an alternative to having the Anti-Fraud Reward Program language in the poster itself, the employer may elect to attach the Anti-Fraud Reward Program Notice to the poster on a separate piece of paper, with the same form and contract as DI4-1549, "Anti-Fraud Reward Program Notice", (Rev 12/02), which is incorporated herein by reference.

(2) The following information shall, in addition to subsection (1) above, be included on the compensation notice if the employer is insured through a commercial insurer; (a) The name and address of the employer; and (b) The name and address of the insurer and the agent of record of the employer's current workers' compensation insurance policy and the policy number and effective date of coverage of that policy. (3) The following information shall, in addition to subsection (1) above, be included on the compensation notice if the employer is self-insured through a self-insurance fund: (a) The name and address of the employer; (b) The name of self-insurers fund to which the employer belongs; (c) The employer's membership number; (d) The effective date of coverage; and (e) The service agent employer's account number. (4) The compensation notice may also include such other information, in addition to information required by subsections (1), (2), and (3) above, as the insurer or self-insurance fund may desire concerning accident reports, the names of physicians, or other pertinent information. (5) Printers, insurers, self insurers or self insurer funds may obtain an electronic version of the art work for the compensation notices from: The Florida Division of Workers' Compensation Customer Service Center 200 East Gaines Street Tallahassee, FL 32399-4227 Specific Authority 440.40 FS. Law Implemented 440.40 FS. History-New 11-20-79, Amended 4-15-81, 1-2-86, Formerly 38F-6.07, Amended 2-2-00, Formerly 38F-6.007, Amended 3-26-03.