Fillable Printable 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:

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

1111 NE 25

Ave., Suite # 403

Ocala FL 34470

Telephone (352) 369-2806

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

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

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."