Free DWC 250 Instructions - Florida

INSTRUCTIONS FOR COMPLETING NOTICE OF ELECTION TO BE EXEMPT IMPORTANT INFORMATION: Only corporate officers or members of a limited liability company (LLC) engaged in the construction industry are eligible for an exemption. Nonconstruction LLC members are NOT ELIGIBLE for an exemption. The Division has 30 days to review your application to determine if it meets the eligibility requirements for the issuance of an exemption. The Division will either issue a Certificate of Election to be Exempt or notify you by mail that your application is incomplete and what information or documents are needed to complete the application. The Division reviews and processes exemption applications in the order they are received. Applicants that are applying to renew a current exemption should submit the application to the Division at least 45 days prior to the expiration date of their current exemption. You can visit the Division's website at http://www.myfloridacfo.com/WC/ and click on the Proof of Coverage icon on the right hand side of the page. Your exemption information will be reflected on the Proof of Coverage database the day following the issuance of the exemption. The Certificate of Election to be Exempt will be mailed to the address shown on the application no later than the second business day after issuance. Allow 7-10 days mailing time. If your corporation is dissolved or inactive, your Notice of Election to be Exempt will be DENIED. If the Notice of Election to be Exempt is denied, the applicant must submit a new Notice of Election to be Exempt and, if the applicant is engaged in the construction industry, another $50.00 fee is required. An exemption is subject to revocation if the person named on the certificate no longer meets any of the requirements to be eligible for an exemption. If you have any questions in regards to completing this application, please call the Division's Customer Service Center at (850) 413-1609 and press option #2. SECTION 1. Print your name and social security number or individual taxpayer identification number. Please list your e-mail address. In addition to mailing a future renewal application to you at the address listed in Section 4, the Division will also e-mail the renewal application to you. "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." SECTION 2. If you are applying for an exemption as an officer of a corporation or member of a limited liability company engaged in the construction industry, you must check one of the boxes beneath the heading "CONSTRUCTION INDUSTRY" ($50 FEE REQUIRED). The Division will accept a money order or a cashier's check made payable to the DFS WC Administration Trust Fund. If you are applying as an officer of a corporation, you must list your corporate title (no abbreviations please). If you are applying for exemption as an officer of a corporation not engaged in the construction industry, you must check the box next to "Officer of a Corporation" beneath the heading NON-CONSTRUCTION INDUSTRY (NO FEE REQUIRED), and list your corporate title (no abbreviations please). SECTION 3. The registration number is the document number that was assigned to your corporation or limited liability company by the Florida Division of Corporations when your corporation or limited liability company was established. This number can be found on your annual report that you have filed with the Florida Division of Corporations. Your document number can also be found at the Florida Division of Corporation's website, http://www.sunbiz.org/. Your corporation or limited liability company must be registered with the Florida Division of Corporations. For applicants applying as an officer of a corporation, you must be listed as an officer of the Corporation with the Florida Division of Corporations. SECTION 4. This section should be completed with information that is specific to your corporation, or to the limited liability company in which you are a member. Please include your complete corporate name, including Inc. or Corp., or the complete name of the limited liability company. The name of the corporation or limited liability company listed on the application must match the name of the corporation or limited liability company registered with the Florida Division of Corporations. If applicable, include your fictitious name, doing business as (DBA) name, or also known as name (AKA) in the `Business Name' field. In the applicant's address of record area, list only one complete address, including suite or apartment number. The certificate of exemption, future renewal applications, and any official correspondence will be mailed to the address listed in this section. A federal employer identification number (FEIN) is required unless the application is for a single member limited liability company in which case the member's social security number will suffice for the limited liability company's FEIN. For information regarding FEIN, you may call the IRS at (800) 829-4933. The certificate applies only to the corporation or limited liability company listed in this section. A new certificate must be obtained for each new or additional corporation or limited liability company employing the applicant. Scope of Trade or Business of Applicant refers to the trade or business activity that best describes your business. The issued certificate of exemption will apply only within the scope of the business or trade listed. You may list up to four trades or scopes of business activity.

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

SECTION 5. Certified or Registered licenses refer to any licenses that are issued by the Department of Business and Professional Regulations (DBPR) as required by Chapter 489 F.S. Contractors are required to obtain a certified or registered license from DBPR. If you need additional information about DBPR licensing requirements, please contact DBPR at (850) 487-1395 or visit their website at http://www.myflorida.com/dbpr. If the applicant is required to obtain a license as required by Chapter 489 F.S., the business name listed on the license must match the name of the corporation or limited liability company listed on the Notice of Election to be Exempt. SECTION 6. If the applicant has submitted an electronic payment for the application, the applicant must list the transaction confirmation number. SECTION 7. This section only applies to those applicants engaged in the construction industry. If the corporation (including any limited liability company) of which you are an officer is affiliated with other corporations, (including limited liability companies), please list the name and FEIN of each such affiliated corporation (including limited liability companies). If there is more than one affiliated corporation (including limited liability companies), please attach a separate sheet identifying the affiliated corporations (including limited liability companies). If the corporation (including any limited liability company) of which you are an officer is not affiliated with any other corporation, (including limited liability companies), based upon the definition of "Affiliated Corporation" below, please indicate "Not Applicable." For purposes of determining whether there are affiliated corporations of the corporation for which you are an officer, pursuant to Section 440.02 (15)(b)2., F.S., the following statutory definition applies: Affiliated corporations means and includes one or more corporations or entities, any one of which is a corporation engaged in the construction industry, under the same or substantially the same control of a group of business entities which are connected or associated so that one entity controls or has the power to control each of the other business entities. The term "affiliated" includes, but is not limited to, the officers, directors, executives, shareholders active in management, employees, and agents of the affiliated corporation. The ownership by one entity or a pooling of equipment or income among business entities shall be prima facie evidence that one business is affiliated with the other. No more than three (3) officers of a corporation (including limited liability companies) or of any group of affiliated corporations (including limited liability companies) may elect to be exempt. SECTION 8. This section only applies to construction industry exemption applicants. Non-construction industry applicants do not need to complete this section. A. CORPORATION - The applicant for a construction industry exemption must attach copies of the stock certificate(s) evidencing at least 10% ownership in the corporation. There is no requirement for a corporate seal or for the certificate to be notarized. At a minimum, each stock certificate must include: · · · · The name of the issuing corporation. The state under which the corporation is organized. The name of the person to whom the certificate is issued. An officer of the corporation must sign the certificate · The percent of ownership that the issued shares represent (a stock register can be provided in lieu of this requirement). · The number of shares issued by the corporation.

B. LIMITED LIABILITY COMPANY - The applicant for a construction industry exemption must produce documentation reflecting that the applicant owns at least 10% of the limited liability company, or submit a statement attesting that the applicant owns at least 10% of the limited liability company. SECTION 9. Each applicant must read the fraud notice and provide his or her signature in the appropriate area. The signature is an attestation that the fraud notice was read, understood and acknowledged. SECTION 10. List the name of the workers' compensation insurance carrier that covers your non-exempt employees. If you do not have nonexempt employees please indicate "not applicable." If you are in the construction industry, workers' compensation coverage must be secured once you employ one or more employees. If you are in the non-construction industry, workers' compensation coverage must be secured once you employ four or more employees. NOTE: Corporate officers are counted as employees unless they have been issued a certificate of election to be exempt from the Division of Workers' Compensation. Failure to secure workers' compensation coverage as defined in S. 440.107(2), F.S., shall result in the issuance of a stop-work order and an order of penalty assessment. AFFIDAVIT OF APPLICANT: An affidavit is a sworn statement in writing made under oath or on affirmation before an authorized officer. This section should be completed after careful review of the statement being attested to. The application should not be signed or dated until you are in the presence of a notary public. NOTARY PUBLIC: The application must be notarized prior to submission. Any licensed notary public may notarize the application. They should not be related to you. Most banks have a notary public available to notarize documents. There may be a charge for this service. Please be advised that workers' compensation office personnel do not notarize applications for Notice of Election to be Exempt.

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