Notice Of Revocation Of Election To Be Exempt
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1
2NOTICE OF REVOCATION OF
ELECTION TO BE EXEMPT
_________________________________________________________________________
NAME OF EXEMPTION HOLDER
A Revocation of Election to be Exempt shall only be filed by the same person named on the Certificate of Election to
be Exempt or by a corporate officer of the business named on the Certificate of Election to be Exempt and listed as a
corporate officer with the Department of State, Division of Corporations.
I hereby revoke the exemption as a (check only one box in this section):
CONSTRUCTION INDUSTRY
Corporate Officer (your corporate title: ____________________)
-OR-
Member of Limited Liability Company
NON-CONSTRUCTION INDUSTRY
Corporate Officer (your corporate title: ____________________)
-OR-
Member of Limited Liability Company
THIS REVOCATION OF ELECTION TO BE EXEMPT APPLIES ONLY TO THE PERSON NAMED ON THIS FORM
AND ONLY TO THE CORPORATION/LLC THAT IS LISTED IN THIS SECTION:
Corporation or Limited Liability Company Name:
Exemption Holder’s Address of Record:
City:
State:
Zip:
County:
Phone No.:
FEIN:
Document Number on file with the Division
(
)
of Corporations:
You must identify the workers’ compensation insurance carrier that covers any non-exempt employees of your
business.
Carrier Name: _________________________________________________________________
PURSUANT TO SECTION 440.05 (3) FLORIDA STATUTES, UPON FILING A NOTICE OF REVOCATION, IF YOU
ARE AN OFFICER WHO IS A SUBCONTRACTOR OR AN OFFICER OF A CORPORATE SUBCONTRACTOR, YOU
MUST NOTIFY YOUR CONTRACTOR THAT YOU HAVE REVOKED YOUR EXEMPTION.
PURSUANT TO SECTION 440.05 (3) FLORIDA STATUTES, UPON REVOCATION OF A CERTIFICATE OF
ELECTION OF EXEMPTION BY THE DEPARTMENT, THE DEPARTMENT SHALL NOTIFY THE WORKERS’
COMPENSATION CARRIER(S) IDENTIFIED IN THE REQUEST FOR EXEMPTION.
Name of Individual Requesting this Revocation: _________________________________________
____________________________________________________
____________________________________
SIGNATURE
DATE SIGNED
DFS-F2-DWC-250-R, NOTICE OF REVOCATION OF ELECTION TO BE EXEMPT - REVISED 08-13
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