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Fillable Printable Workers Compensation Exemption Form - Florida

Fillable Printable Workers Compensation Exemption Form - Florida

Workers Compensation Exemption Form - Florida

Workers Compensation Exemption Form - Florida

DWC 250, NOTICE OF ELECTION TO BE EXEMPT – REVISED 12/08; RULE 69L-6.009, F.A.C.
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 12/08; RULE 69L-6.009, F.A.C.
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 business.
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
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
SECTION 10. You must identify the workers’ compensation insurance carrier that covers any non-exempt employees of your
business. Carrier Name:
STATE USE ONLY
Effective/Issue Date:
____________________________
Expiration Date:
____________________________
Control Number:
____________________________
Postmark Date:
____________________________
Payment Number:
____________________________
Received Date:
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 or
(407) 245-0896
499 Northwest 70
th
Ave., 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 2
nd
Avenue
Suite #321, South Tower
Miami FL 33128
Telephone (305) 536-0306
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
"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."
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