Notice Of Revocation Of Election To Be Exempt
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Effective/Issue Date:
NOTICE OF REVOCATION OF
________________________________
ELECTION TO BE EXEMPT
Control Number:
________________________________
Postmark Date:
________________________________
Received Date:
PLEASE TYPE OR PRINT
I hereby revoke the exemption I currently have as a (check only one box in this section):
CONSTRUCTION INDUSTRY
Corporate Officer (your corporate title: ____________________)
Member of Limited Liability Company
-OR-
NON-CONSTRUCTION INDUSTRY
Corporate Officer (your corporate title: ____________________)
THIS REVOCATION OF ELECTION TO BE EXEMPT APPLIES ONLY TO THE PERSON SIGNING THE
REVOCATION AND ONLY TO THE CORPORATION/LLC THAT IS LISTED IN THE FOLLOWING SECTION:
Corporation or LLC Name:
Business Mailing Address:
City:
State:
Zip:
County:
Phone No.:
FEIN:
Corporate registration number:
(
)
Scope of Business or Trade of Applicant Listed on Notice of Election to be Exempt:
1. ______________________ 2. ________________________ 3. ________________________ 4. _____________________
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.
_____________________________________________________________________________________________________________________
TYPE/PRINT NAME OF EXEMPTION HOLDER
___________________________________________________________
____________________________________
SIGNATURE OF EXEMPTION HOLDER
DATE SIGNED
WORKERS’ COMPENSATION INFORMATION ONLINE -
DWC 250-R, NOTICE OF REVOCATION OF ELECTION TO BE EXEMPT - REVISED 12/08; RULE 69L-6.009, F.A.C.
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