Aggregate Claims Administration Change Report {DWC-49}

SENT TO DIVISION DIVISION RECEIVED AGGREGATE CLAIMS ADMINISTRATION CHANGE REPORT DATE 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: __________________________________ NAME OF SERVICING CO./TPA: __________________________________ ADDRESS: ____________________________________________________ ADDRESS: ____________________________________________________ ______________________________________________________ ______________________________________________________ TELEPHONE: __________________________________________________ TELEPHONE: __________________________________________________ SERVICING CO./TPA CODE #: __ __________________________________ SERVICING CO./TPA CODE #: __ __________________________________ NAME OF INSURER, FUND, SELF-INSURED EMPLOYER: NAME OF INSURER, FUND, SELF-INSURED EMPLOYER: _________________________________________________ _________________________________________________ INSURER CODE #: ______________________________________________ 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 DATE OF ACCIDENT SOCIAL SECURITY NUMBER  EMPLOYEE NAME (First, Middle, Last) EMPLOYER (Month-/Day/Year) INSURER NAME: PLEASE ATTACH ADDITIONAL PAGE(S) OF THIS FORM IF NECESSARY, OR A LISTING IDENTICAL IN FORMAT (EMPLOYEE, SSN, D/A, CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE EMPLOYER) 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-insured 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 (08/2004)