Form DEP55-241 "Worker's Compensation Exemption Form" - Florida

What Is Form DEP55-241?

This is a legal form that was released by the Florida Department of Environmental Protection - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2004;
  • The latest edition provided by the Florida Department of Environmental Protection;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form DEP55-241 by clicking the link below or browse more documents and templates provided by the Florida Department of Environmental Protection.

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Download Form DEP55-241 "Worker's Compensation Exemption Form" - Florida

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Department of Environmental Protection
Exemption from Workers’ Compensation Insurance Requirements
for Non-Construction Organizations ONLY
Company Name: __________________________________________________________________________
FEID #/SS#: _____________________________________
Entity Information:
Sole Proprietor
Partner
Total number of sole proprietors/partners:_______________
Total number of sole proprietors/partners electing coverage:_______________
(Include copy of Notice of Election of Coverage, DWC 251 or BCM 251)
Corporation
Limited Corporation
Total number of corporate officers:_______________
Total number of corporate officers electing exemption:_______________
(Include copy of Notice of Election to be Exempt, DWC 250 or BCM 250)
Total number of employees, other than sole proprietor, partners or corporate officers:_________
The above-referenced company is exempt from the requirement to carry workers' compensation insurance due to: (check one)
Less than four (4) employees pursuant to 440.02(17)(a)(2), Florida Statutes
Notice of Election to be Exempt, DWC2 50 or BCM 250 form, filed with the Division of Workers’ Compensation.
Since the above-referenced organization is not required by state law to obtain worker’s compensation insurance, the
organization hereby agrees that the Department of Environmental Protection will not be liable for any worker’s compensation
related claims that may arise in relation to DEP Purchase Order/Contract/Agreement No.
.
____________________________________________________
Signature of Person Authorized to Bind Organization
____________________________________________________
Typed/Printed Name
____________________________________________________
Date
____________________________________________________
Telephone Number
DEP 55-241(02-04)
Department of Environmental Protection
Exemption from Workers’ Compensation Insurance Requirements
for Non-Construction Organizations ONLY
Company Name: __________________________________________________________________________
FEID #/SS#: _____________________________________
Entity Information:
Sole Proprietor
Partner
Total number of sole proprietors/partners:_______________
Total number of sole proprietors/partners electing coverage:_______________
(Include copy of Notice of Election of Coverage, DWC 251 or BCM 251)
Corporation
Limited Corporation
Total number of corporate officers:_______________
Total number of corporate officers electing exemption:_______________
(Include copy of Notice of Election to be Exempt, DWC 250 or BCM 250)
Total number of employees, other than sole proprietor, partners or corporate officers:_________
The above-referenced company is exempt from the requirement to carry workers' compensation insurance due to: (check one)
Less than four (4) employees pursuant to 440.02(17)(a)(2), Florida Statutes
Notice of Election to be Exempt, DWC2 50 or BCM 250 form, filed with the Division of Workers’ Compensation.
Since the above-referenced organization is not required by state law to obtain worker’s compensation insurance, the
organization hereby agrees that the Department of Environmental Protection will not be liable for any worker’s compensation
related claims that may arise in relation to DEP Purchase Order/Contract/Agreement No.
.
____________________________________________________
Signature of Person Authorized to Bind Organization
____________________________________________________
Typed/Printed Name
____________________________________________________
Date
____________________________________________________
Telephone Number
DEP 55-241(02-04)