Form Bcm-250-R - Revocation Of Election To Be Exempt Form printable pdf download

Form Bcm-250-R - Revocation Of Election To Be Exempt Form

STATE USE ONLY

Effective/Issue Date:

REVOCATION OF

________________________________

ELECTION TO BE EXEMPT

Control Number:

________________________________

Postmark Date:

________________________________

Received Date:

PLEASE TYPE OR PRINT

I hereby revoke an exemption I currently hold as a (check only one box in this section):

CONSTRUCTION INDUSTRY

OR-

Sole Proprietor

Partner

Corporate Officer (your corporate title:____________________ ) -

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 BUSINESS ENTITY LISTED IN THE FOLLOWING SECTION:

Business Name:

Trade Name; d/b/a; or a/k/a:

Business Mailing Address:

City:

State:

Zip:

County:

Phone No.:

Nature of Business:

FEIN:

(

)

Unemployment Compensation

Date Business Established:

No. of Employees:

Sec. Of State, Div. Of Corp.

Tax No:

Reg. No.:

I UNDERSTAND THAT IF I AM A SOLE PROPRIETOR, PARTNER, OR CORPORATE OFFICER AND I AM A

SUBCONTRACTOR I MUST NOTIFY MY CONTRACTOR THAT I HAVE REVOKED MY EXEMPTION.

NOTIFICATION THAT YOU HAVE CHOSEN TO REVOKE YOUR EXEMPTION FROM CHAPTER 440, FLORIDA STATUTES

SHALL BE GIVEN BY THE DIVISION TO ANY INSURER ON RECORD WITH THE DIVISION AS A PROVIDER OF

WORKERS’ COMPENSATION INSURANCE TO THE BUSINESS ENTITY NAMED HEREIN.

______________________________________________________________________

___________________________________________________

TYPE/PRINT NAME OF EXEMPTION HOLDER

SOCIAL SECURITY NO.

_______________________________________________________________

______________________________________________

SIGNATURE OF EXEMPTION HOLDER

DATE SIGNED

Revised

LES FORM BCM-250-R

February 2000

Form Bcm-250-R - Revocation Of Election To Be Exempt Form

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