Les Form Bcm-250 - Notice Of Election To Be Exempt
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1NOTICE OF ELECTION TO BE EXEMPT
STATE USE ONLY
Please refer to the written instructions prepared by the
Effective/Issue Date:
Division of Workers’ Compensation before completing this form.
____________________________
Expiration Date:
By filing this application, you elect to be exempt from the provisions of Chapter 440,
____________________________
Florida Statutes and waive any right you may have to workers’ compensation benefits in
Control Number:
the State of Florida should you become injured on the job. Any person who knowingly and
____________________________
with intent to injure, defraud, or deceive the Division or any employer, employee, or
Postmark Date:
insurance company or purposes program, files a Notice of Election to be Exempt containing
____________________________
any false or misleading information is guilty of a felony of the third degree. Certain
Received Date:
documentation is required by law to be attached to this application-refer to the instruction
sheet for more details.
I am applying for exemption as a (check only one box in this section):
CONSTRUCTION INDUSTRY ( $ 50.00 FEE REQUIRED)
Sole Proprietor
Partner
Corporate Officer (your corp. title:____________________ )
-OR-
NON-CONSTRUCTION INDUSTRY ( NO FEE REQUIRED)
)
Corporate Officer (your corp. title:____________________
CORPORATE OFFICERS AND PARTNERS: List the registration number of your business on file with the Division of Corporations,
Department of State’s Office (NOTE: your partnership may not have one, but all corporations must have one. If your partnership doesn’t
have one, state “N/A”): __________________________________________________________________________
THIS EXEMPTION APPLICATION APPLIES ONLY TO THE PERSON SIGNING THE APPLICATION
AND ONLY FOR 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:
Tax No:
Are you required to be registered or certified pursuant to Chapter 489, F. S.?
No
Yes: list all certified or registered
licenses issued to you pursuant to Chapter 489, Florida Statues________________________________________________
Are you or a qualifier for your business required by the county or the municipality in which your business mailing address is
located to have an occupational license for the business which is the subject of this application?
No
Yes:
YOU MUST ATTACH A COPY OF A CURRENT OCCUPATIONAL LICENSE
Are you employed by any sole proprietorship, partnership, corporation or business entity other than the business to which this application
applies?
NO
YES list the name of all other businesses in which you are employed: _________________________________
_____________________________________________________________________________________________________________
Has the above-referenced business entity been in operation long enough to have filed with or be required to file by the IRS,
an annual Federal Income Tax Return?
No
Yes, You must attach tax records. See instruction sheet for details.
AFFIDAVIT OF APPLICANT:
I hereby certify that the information contained herein is true and correct to the best of my
knowledge and belief; that this election does not exceed exemption limits for corporate officers or partners as provided in §440.02
Florida Statutes; and that I will secure the payment of workers’ compensation benefits, pursuant to Chapter 440, Florida Statutes,
for any employee I now have or may hereinafter acquire, for which my business is required by Florida law to secure such benefits.
______________________________________________________________________
_______/_________/_______
________/________/_______
.
mo.
day
yr.
TYPE/PRINT NAME OF PERSON APPLYING FOR EXEMPTION
SOCIAL SECURITY NO
DATE OF BIRTH
______/_______/________
________________________________________________________________
APPLICANT’S SIGNATURE
DATE SIGNED
NOTARY STATE OF FLORIDA, COUNTY OF ________________________
Sworn to and subscribed before me this______ day of ____________, _____________, by __________________________________________________
Personally Known________ OR Produced Identification_________ Type of Identification Produced____________________________________________
NOTARY SIGNATURE __________________________________________ My Commission Expires ________________________________________
LES FORM BCM-250 Revised February 2000
(SEE REVERSE FOR ADDITIONAL INFORMATION)
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