STATE USE ONLY Effective/Issue Date: NOTICE OF REVOCATION OF ELECTION TO BE EXEMPT ________________________________ 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: ____________________) Member of Limited Liability Company -OR- NON-CONSTRUCTION INDUSTRY Corporate Officer (your corporate title: ____________________) 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: County: City: Phone No.: ( ) State: FEIN: Zip: 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 11/11; RULE 69L-6.009, F.A.C. American LegalNet, Inc. www.FormsWorkFlow.com SUBMIT THIS FORM TO THE DISTRICT OFFICE LISTED BELOW THAT IS CLOSEST TO YOUR PLACE OF BUSINESS: WORKERS’ COMPENSATION COMPLIANCE FIELD OFFICES 2295 Victoria Avenue, Suite 163 Ft. Myers, FL 33901 Telephone (239) 461-4006 610 E. Burgess Road Pensacola, FL 32504-6320 Telephone (850) 453-7804 3111 S. Dixie Highway, Suite # 123 West Palm Beach FL 33405 Telephone (561) 837-5716 1313 N. Tampa Street, Suite # 503 Tampa FL 33602 Telephone (813) 221-6506 921 North Davis Street Building B, Suite #250 Jacksonville, FL 32209 Telephone (904) 798-5806 499 Northwest 70th Ave., Suite # 116 Plantation FL 33317 Telephone (954) 321-2906 400 West Robinson Street Room #512, North Tower Orlando FL 32801 Telephone (407) 835-4406 TALLAHASSEE SUBMITTERS 401 NW 2nd Avenue Suite #321, South Tower Miami FL 33128 Telephone (305) 536-0306 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 11/11; RULE 69L-6.009, F.A.C. American LegalNet, Inc. www.FormsWorkFlow.com