Workers' Compensation Insurance Exemption printable pdf download

Notice to Owner – Workers’ Compensation Insurance Exemption

Florida Law requires Workers’ Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. §

440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any

construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers’ Compensation

Employer Facts Brochure:

An employer in the construction industry who employs one or more part-time or full-time

employees, including the owner, must obtain workers’ compensation coverage.

Corporate officers or members of a limited liability company (LLC) in the construction

industry may elect to be exempt if:

1. The officer owns at least 10 percent of the stock of the corporation, or in the

case of an LLC, a statement attesting to the minimum 10 percent ownership;

2. The officer is listed as an officer of the corporation in the records of the

Florida Department of State, Division of Corporations; and

3. The corporation is registered and listed as active with the Florida Department

of State, Division of Corporations.

No more than three corporate officers per corporation or limited liability company

members are allowed to be exempt. Construction exemptions are valid for a period of

two years or until a voluntary revocation is filed or the exemption is revoked by the

Division.

Your contractor is requesting a permit under this workers’ compensation exemption. In these circumstances, the City of

North Miami Beach does not require verification of workers’ compensation insurance coverage from the contractor’s

company.

Therefore, you may be personally liable for the worker compensation injuries of any person allowed to work under this

permit. Please check with your insurance carrier since most property insurance policies DO NOT cover this type of

liability.

BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND

ITS CONTENTS.

Owner

Contractor

Print Name: __________________________

Print Name:__________________________

Signature: ____________________________

Signature:____________________________

State of Florida )

County of Miami-Dade )

Sworn to and subscribed before me this _______

day of _________________ , 20_____.

By ____________________________________

By____________________________________

(SEAL) ________________________________

(SEAL)________________________________

Type of Identification produced________________

Type of Identification produced_______________

Avenue  North Miami Beach, FL 33162-3194  (305) 948-2965  (305) 919-3708 

17050 NE 19

Workers' Compensation Insurance Exemption

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