Form Dfs K4 1055 PDF Details

Are you familiar with the Form DfS K4 1055? It's a form created by the Department of Financial Services (DFS) in New York for all employers who provide health coverage to their employees. This is an important document because it provides information about health insurance policy benefits, employment conditions, and compliance requirements mandated by state and federal law. In this blog post, we'll explain everything you need to know about how to prepare and submit your Form Dfs K4 1055 in order to keep compliant with state laws. So if you're looking for an overview of what's required from employers providing healthcare plans in New York State, look no further!

QuestionAnswer
Form NameForm Dfs K4 1055
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesform dfs k4 1055, FIANCIAL, NW, GAINESVILLE

Form Preview Example

THE DEPARTMENT OF FIANCIAL SERVICES

Division of the State Fire MarshalAction may be completed at www.floridastatefirecollege.org

FIREFIGHTERS SUPPLEMENTAL COMPENSATION PROGRAM

NOTICE OF INELIGIBILITY

BUREAU OF FIRE STANDARDS & TRAINING

Please type or print requested information legibly.

NAME OF FIREFIGHTER: LAST

FIRST

M.I.

MAIDEN NAME (If applicable)

 

 

 

 

 

 

 

HOME ADDRESS

CITY

 

 

 

STATE

ZIP CODE

 

 

 

 

 

 

 

SOCIAL SECURITY NUMBER1

 

 

 

 

 

TELEPHONE #

 

 

 

 

 

 

 

NAME OF FIRE DEPARTMENT

 

 

 

 

 

 

 

 

 

 

 

 

FIRE CHIEF/AUTHORIZED AGENT

 

 

 

 

DEPARTMENT TELEPHONE #

 

 

 

 

 

 

 

DEPARTMENT MAILING ADDRESS

CITY

 

 

 

STATE

ZIP CODE

Reason for Change in Eligibility Status:

Transferred or Reclassified

(no longer serving as a full-time firefighter)

Employment Terminated

Leave of Absence

(without pay)

Suspended Suspended

(without pay)

Date of Ineligibility:

(FIRST DAY OF INELIGIBILITY, NOT LAST WORKING DAY)

PLEASE BE SURE TO SUBMIT THE REQUIRED NOTICE OF TERMINATION FORM DFS-K4-1033

SIGNATURE OF FIRE CHIEF OR AUTHORIZED AGENT

DATE

NOTE: THIS FORM IS TO BE SUBMITTED BY THE EMPLOYING AGENCY WITHIN

TEN (10) BUSINESS DAYS OF INELIGIBILITY TO THE:

BUREAU OF FIRE STANDARDS & TRAINING

11655 NW GAINESVILLE ROAD, OCALA, FLORIDA 34482-1486

01

07

02

08

03

09

Bureau Use Only

04

10

Effective Date:

05

06

11

12

Recorded by:

 

Date:

1Please note that the social security number is not required; however, if you provide it, it will greatly assist us in assisting you.

DFS-K4-1055 REV 03/06

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