Dbpr El 4502 Form PDF Details

In the intricate landscape of Florida's professional regulation, the DBPR EL-4502 form serves a crucial role that touches upon several facets of administrative compliance and workforce management. This form is specifically designed to streamline communication between licensed employee leasing companies and significant regulatory bodies including the workers' compensation insurance carrier, the Division of Workers' Compensation, and the Department of Revenue. As mandated by Chapter 468.529(3), Florida Statutes, the form acts as a notification tool for the initiation or termination of any client company relationship, ensuring that these significant transitions are officially recorded within a 30-day window. Details required on the form encapsulate basic yet essential information about both the employee leasing company and the client company, covering identification numbers, addresses, and contact details, alongside specifics of the leasing arrangement such as dates and employee details. By fulfilling this requirement, companies adhere to regulatory expectations, foster transparency with state agencies, and maintain an organized record of their contractual dynamics. The emphasis on keeping and sharing completed forms with relevant parties further underlines the importance of this document in the broader context of regulatory compliance and operational integrity within Florida's business environment.

QuestionAnswer
Form NameDbpr El 4502 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesftb 4502 form, fl dbpr 4502, va form 4502 printable version, dbpr el4502

Form Preview Example

DBPR EL-4502 – Client Initiation or Termination Form

STATE OF FLORIDA

DEPARTMENT OF BUSINESS AND

PROFESSIONAL REGULATION

Chapter 468.529(3), Florida Statutes, requires that a licensed employee leasing company shall, within 30 days of initiation or termination, notify its workers' compensation insurance carrier, the Division of Workers' Compensation, and the Department of Revenue of both the initiation and termination of the company's relationship with any client company.

EMPLOYEE LEASING COMPANY INFORMATION

 

Company Name

 

 

 

 

 

 

 

 

License #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address or P.O. Box

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

 

Zip Code (+4 optional)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Person

 

Phone #

 

 

 

 

 

Fax #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Federal Tax ID #

 

 

 

State UCT #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLIENT COMPANY INFORMATION

 

 

 

 

 

 

Client Company Name

 

 

 

 

 

 

 

 

License #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address or P.O. Box

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

 

Zip Code (+4 optional)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Person

 

Phone #

 

 

 

 

 

Fax #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Federal Tax ID #

 

 

 

State UCT #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date leasing arrangement entered into:_________

 

Date leasing arrangement terminated:

 

 

Employees Leased: All_____

Part_____

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

W/C class codes used in that location:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Completed by:

 

 

 

 

 

Title: ________________________

 

 

 

 

(please print name)

 

 

 

 

(please print title)

 

 

 

 

 

 

 

 

 

 

Date

_

 

 

 

 

(Signature)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Be sure to do the following:

(1)Keep a copy of this completed form for your records.

(2)Furnish a copy of this completed form to your workers’ compensation carrier AND the following:

Dept. of Revenue

Dept. of Financial Services

General Tax Administration

Division of Workers' Compensation

Return and Revenue Processing

200 East Gaines Street

5050 West Tennessee Street

Tallahassee, FL 32399-4224

Tallahassee, FL 32399-0100

 

DBPR EL-4502

Page 1 of 1

Employee Leasing: Client Initiation or Termination Form

Effective Date 5/2011

 

Rule: 61G7-10.0013

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