Free DWC 250-R - Florida

STATE USE ONLY

NOTICE OF REVOCATION OF ELECTION TO BE EXEMPT

Effective/Issue Date: ________________________________ Control Number: ________________________________ Postmark Date: ________________________________ Received Date:

PLEASE TYPE OR PRINT
I hereby revoke the exemption I currently have as a (check only one box in this section): CONSTRUCTION INDUSTRY Corporate Officer (your corporate title: ____________________) NON-CONSTRUCTION INDUSTRY Corporate Officer (your corporate title: ____________________)

Member of Limited Liability Company

-OR-

THIS REVOCATION OF ELECTION TO BE EXEMPT APPLIES ONLY TO THE PERSON SIGNING THE REVOCATION AND ONLY TO THE CORPORATION/LLC THAT IS LISTED IN THE FOLLOWING SECTION: Corporation or LLC Name:

Business Mailing Address:

City:

State:

Zip:

County:

Phone No.: ( )

FEIN:

Corporate registration number:

Scope of Business or Trade of Applicant Listed on Notice of Election to be Exempt: 1. ______________________ 2. ________________________ 3. ________________________ 4. _____________________ You must identify the workers' compensation insurance carrier that covers any non-exempt employees of your business. Carrier Name: _________________________________________________________________ PURSUANT TO SECTION 440.05 (3) FLORIDA STATUTES, UPON FILING A NOTICE OF REVOCATION, IF YOU ARE AN OFFICER WHO IS A SUBCONTRACTOR OR AN OFFICER OF A CORPORATE SUBCONTRACTOR, YOU MUST NOTIFY YOUR CONTRACTOR THAT YOU HAVE REVOKED YOUR EXEMPTION. PURSUANT TO SECTION 440.05 (3) FLORIDA STATUTES, UPON REVOCATION OF A CERTIFICATE OF ELECTION OF EXEMPTION BY THE DEPARTMENT, THE DEPARTMENT SHALL NOTIFY THE WORKERS' COMPENSATION CARRIER(S) IDENTIFIED IN THE REQUEST FOR EXEMPTION.

_____________________________________________________________________________________________________________________

TYPE/PRINT NAME OF EXEMPTION HOLDER ___________________________________________________________ SIGNATURE OF EXEMPTION HOLDER ____________________________________ DATE SIGNED

WORKERS' COMPENSATION INFORMATION ONLINE - http://www.myfloridacfo.com/wc
DWC 250-R, NOTICE OF REVOCATION OF ELECTION TO BE EXEMPT - REVISED 12/08; RULE 69L-6.009, F.A.C.

SUBMIT THIS FORM TO THE DISTRICT OFFICE LISTED BELOW THAT IS CLOSEST TO YOUR PLACE OF BUSINESS:

WORKERS' COMPENSATION COMPLIANCE FIELD OFFICES

2295 Victoria Ave. Suite 163 Ft. Myers, FL 33901 Telephone (239) 461-4006 610 E. Burgess Road Pensacola, FL 32504-6320 Telephone (850) 453-7804 3111 South Dixie Hwy. Suite #123 West Palm Beach FL 33405 Telephone (561) 837-5716 1313 N. Tampa St. Suite #503 Tampa FL 33602 Telephone (813) 221-6506 1111 NE 25th Ave. Suite #403 Ocala FL 34470 Telephone (352) 401-5350

921 N. Davis St. Building B, Suite #250 Jacksonville, FL 32209 Telephone (904) 798-5806 400 West Robinson St. Room #512 North Tower Orlando FL 32801 Telephone (407) 245-0896 499 Northwest 70th Avenue Suite #116 Plantation FL 33317 Telephone (954) 321-2906 Live Oak Business Center 5969 Cattlemen Lane Sarasota FL 34232 Telephone (941) 329-1120

401 NW 2nd Ave. Suite #321 South Tower Miami FL 33128 Telephone (305) 536-0306

TALLAHSSEE SUBMITTERS Walk-in submissions: 2012 Capital Circle SE Suite #102 Hartman Bldg. Tallahassee FL 32399-2161 Telephone (850) 413-1609 Mail in submissions: 200 East Gaines Street Tallahassee FL 32399-4228 Telephone (850) 413-1609

WORKERS' COMPENSATION INFORMATION ONLINE - http://www.myfloridacfo.com/wc
DWC 250-R, NOTICE OF REVOCATION OF ELECTION TO BE EXEMPT - REVISED 12/08; RULE 69L-6.009, F.A.C.