Form Dwc 250 - Notice Of Election To Be Exempt (Page 2 of 2) in pdf

NOTICE OF ELECTION TO BE EXEMPT – Page 2

SECTION 9.

FRAUD NOTICE

A. Any person who, knowingly and with intent to injure, defraud, or deceive the department or any employer or

employee, insurance company or any other person, files a notice of election to be exempt containing any false or

misleading information is guilty of a felony of the third degree.

B. Attestation of applicant - By signing below, I attest that I have read, understand and acknowledge the foregoing

notice.

_____________________________________________________________

SIGNATURE OF APPLICANT

SECTION 10. You must identify the workers’ compensation insurance carrier that covers any non-exempt employees of your

business. Carrier Name:

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, including any affiliated

corporations as provided in §440.02 Florida Statutes.

________________________________________________________

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

Please mail or submit your completed application, application fee, and any required attachments

STATE USE ONLY

to The Division of Workers’ Compensation at the district office nearest your place of business.

Effective/Issue Date:

____________________________

2295 Victoria Avenue, Suite 163

921 North Davis Street

401 NW 2

Avenue

Expiration Date:

Ft. Myers, FL 33901

Building B, Suite #250

Suite #321, South Tower

____________________________

Telephone (239) 461-4006

Jacksonville, FL 32209

Miami FL 33128

Telephone (904) 798-5806

Telephone (305) 536-0306

Control Number:

610 E. Burgess Road

Pensacola, FL 32504-6320

____________________________

400 West Robinson Street

TALLAHASSEE SUBMITTERS

Telephone (850) 453-7804

Room #512, North Tower

Postmark Date:

Walk-in submissions:

Orlando FL 32801

3111 S. Dixie Highway, Suite # 123

____________________________

2012 Capital Circle SE

Telephone (407) 835-4406 or

West Palm Beach FL 33405

Suite #102, Hartman Bldg.

Payment Number:

(407) 245-0896

Telephone (561) 837-5716

Tallahassee FL 32399-2161

____________________________

Telephone (850) 413-1609

499 Northwest 70

Ave., Suite # 116

1313 N. Tampa Street, Suite # 503

Received Date:

Plantation FL 33317

Tampa FL 33602

Mail in submissions:

Telephone (954) 321-2906

Telephone (813) 221-6506

200 East Gaines Street

Live Oak Business Center

Tallahassee FL 32399-4228

1111 NE 25

Ave., Suite # 403

5969 Cattlemen Lane

Telephone (850) 413-1609

Ocala FL 34470

Sarasota FL 34232

Telephone (352) 369-2806

Telephone (941) 329-1120

"The collection of the social security number on this form is specifically authorized by Section

440.05(3), Florida Statutes. The social security number will be used as a unique identifier in Division

of Workers' Compensation database systems for individuals who have applied for and/or been

issued a certificate of election to be exempt. It will also be used to identify information and

documents in those database systems regarding individuals who have applied for and/or been

issued a certificate of election to be exempt for internal agency tracking purposes and for purposes

of responding to both public records requests and subpoenas that require production of specified

documents. The social security number may also be used for any other purpose specifically

required or authorized by state or federal law."

DWC 250, NOTICE OF ELECTION TO BE EXEMPT – REVISED 12/08; RULE 69L-6.009, F.A.C.

Form Dwc 250 - Notice Of Election To Be Exempt Page 2

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