NOTICE OF ELECTION TO BE EXEMPT Please thoroughly read the instructions before completing this application. Print legibly in each data entry field. If this application contains incomplete or inaccurate information or if the handwriting is not legible, it may cause a delay in the issuance of your exemption. SECTION 1: Applicant Name (please print): Applicant’s social security number: / / Applicant’s E-mail address (optional): ______________________________________________________ SECTION 2: I am applying for exemption as a (You must check only one box in this section): 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. Officer of a Corporation (Title): __ -OR- Member of a Limited Liability Company (LLC) NON-CONSTRUCTION INDUSTRY (NO FEE REQUIRED) Officer of a Corporation (Title): ) An officer electing an exemption under Chapter 440, Florida Statutes is not entitled to benefits under this chapter. SECTION 3. The corporation of which you are an officer or the limited liability company of which you are a member must be registered and in an active status with the Florida Division of Corporations. Applicants applying as an officer of a corporation must be listed as an officer of the Corporation with the Florida Division of Corporations. List the document number (document number shown on your Annual Report) on file with the Florida Division of Corporations. __________ SECTION 4. This exemption application applies only to the person signing the application, the Corporation/LLC that is listed below, and the scope of business or trade listed: Name of Corporation or LLC: ____________________________________________________________FEIN: ______________ AS REGISTERED WITH THE FLORIDA DIVISION OF CORPORATIONS Business Name: ___________________________________________________________________Phone: ( ) IF APPLICABLE – LIST FICTITIOUS NAME; DOING BUSINESS AS (DBA); ALSO KNOWN AS NAME (AKA) Applicant’s Address of Record: _______________________________________________________________________________ INCLUDE APARTMENT OR SUITE NUMBER City: ____________________________________________State: ________Zip: ______________County: ___________________ Scope of Business or Trade: 1. ___________________2. __________________3. __________________4.___________________ SECTION 5. List all certified or registered licenses issued pursuant to Chapter 489, F.S. held by the applicant, or the certified or registered license numbers held by the qualifier for the corporation or LLC listed on this application of which the applicant is a corporate officer: SECTION 6. If you have submitted an electronic payment for this application, write the transaction confirmation number in the following space: ______________________________________________ SECTION 7. Are you affiliated with any corporation (including LLC) other than the corporation (including LLC) to which this application applies? Yes No IF YES, PLEASE LIST THE NAME(s) AND FEIN(s) OF THE AFFILIATED CORPORATION(s) OR LLC(s): NAME: ___________________________________________________________________ FEIN: _____________________________ SECTION 8. If your corporation or LLC is engaged in the construction industry, you must provide the required proof of ownership in the corporation or LLC. A. To be eligible for a construction industry exemption as an officer of a corporation, the applicant must be a shareholder, owning at least 10% of the stock of the corporation. A COPY OF A STOCK CERTIFICATE EVIDENCING THE REQUIRED OWNERSHIP MUST BE ATTACHED. B. To be eligible for a construction industry exemption as a member of a limited liability company, the applicant must confirm ownership of at least 10% of the company. THE REQUIRED OWNERSHIP MAY BE ESTABLISHED BY PRODUCTION OF DOCUMENTATION REFLECTING THE REQUIRED OWNERSHIP, OR BY SUBMITTING A STATEMENT ATTESTING TO THE REQUIRED OWNERSHIP. THIS APPLICATION IS CONTINUED ON PAGE 2 DWC 250, NOTICE OF ELECTION TO BE EXEMPT – REVISED 11/11; RULE 69L-6.009, F.A.C. American LegalNet, Inc. www.FormsWorkFlow.com 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 to The Division of Workers’ Compensation at the district office nearest your place of b i DWC 250, NOTICE OF ELECTION TO BE EXEMPT – REVISED 11/11; RULE 69L-6.009, F.A.C. American LegalNet, Inc. www.FormsWorkFlow.com STATE USE ONLY Effective/Issue Date: ____________________________ Expiration Date: ____________________________ Control Number: ____________________________ Postmark Date: ____________________________ Payment Number: ____________________________ Received Date: "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." 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 400 West Robinson Street Room #512, North Tower Orlando FL 32801 Telephone (407) 835-4406 401 NW 2nd Avenue Suite #321, South Tower Miami FL 33128 Telephone (305) 536-0306 499 Northwest 70th Ave., Suite # 116 Plantation FL 33317 Telephone (954) 321-2906 TALLAHASSEE 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 DWC 250, NOTICE OF ELECTION TO BE EXEMPT – REVISED 11/11; RULE 69L-6.009, F.A.C. American LegalNet, Inc. www.FormsWorkFlow.com