Form DFS-F2-DWC-250-R "Notice of Revocation of Election to Be Exempt" - Florida

What Is Form DFS-F2-DWC-250-R?

This is a legal form that was released by the Florida Department of Financial Services - 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 August 1, 2013;
  • The latest edition provided by the Florida Department of Financial Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DFS-F2-DWC-250-R by clicking the link below or browse more documents and templates provided by the Florida Department of Financial Services.

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Download Form DFS-F2-DWC-250-R "Notice of Revocation of Election to Be Exempt" - Florida

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NOTICE OF REVOCATION OF
ELECTION TO BE EXEMPT
_________________________________________________________________________
NAME OF EXEMPTION HOLDER
A Revocation of Election to be Exempt shall only be filed by the same person named on the Certificate of Election to
be Exempt or by a corporate officer of the business named on the Certificate of Election to be Exempt and listed as a
corporate officer with the Department of State, Division of Corporations.
I hereby revoke the exemption as a (check only one box in this section):
CONSTRUCTION INDUSTRY
Corporate Officer (your corporate title: ____________________)
-OR-
Member of Limited Liability Company
NON-CONSTRUCTION INDUSTRY
Corporate Officer (your corporate title: ____________________)
-OR-
Member of Limited Liability Company
THIS REVOCATION OF ELECTION TO BE EXEMPT APPLIES ONLY TO THE PERSON NAMED ON THIS FORM
AND ONLY TO THE CORPORATION/LLC THAT IS LISTED IN THIS SECTION:
Corporation or Limited Liability Company Name:
Exemption Holder’s Address of Record:
City:
State:
Zip:
County:
Phone No.:
FEIN:
Document Number on file with the Division
of Corporations:
(
)
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.
Name of Individual Requesting this Revocation: _________________________________________
____________________________________
____________________________________________________
SIGNATURE
DATE SIGNED
EMAIL TO: WC_EXEMPTION@MYFLORIDACFO.COM
PRINT
DFS-F2-DWC-250-R, NOTICE OF REVOCATION OF ELECTION TO BE EXEMPT - REVISED 08-13
NOTICE OF REVOCATION OF
ELECTION TO BE EXEMPT
_________________________________________________________________________
NAME OF EXEMPTION HOLDER
A Revocation of Election to be Exempt shall only be filed by the same person named on the Certificate of Election to
be Exempt or by a corporate officer of the business named on the Certificate of Election to be Exempt and listed as a
corporate officer with the Department of State, Division of Corporations.
I hereby revoke the exemption as a (check only one box in this section):
CONSTRUCTION INDUSTRY
Corporate Officer (your corporate title: ____________________)
-OR-
Member of Limited Liability Company
NON-CONSTRUCTION INDUSTRY
Corporate Officer (your corporate title: ____________________)
-OR-
Member of Limited Liability Company
THIS REVOCATION OF ELECTION TO BE EXEMPT APPLIES ONLY TO THE PERSON NAMED ON THIS FORM
AND ONLY TO THE CORPORATION/LLC THAT IS LISTED IN THIS SECTION:
Corporation or Limited Liability Company Name:
Exemption Holder’s Address of Record:
City:
State:
Zip:
County:
Phone No.:
FEIN:
Document Number on file with the Division
of Corporations:
(
)
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.
Name of Individual Requesting this Revocation: _________________________________________
____________________________________
____________________________________________________
SIGNATURE
DATE SIGNED
EMAIL TO: WC_EXEMPTION@MYFLORIDACFO.COM
PRINT
DFS-F2-DWC-250-R, NOTICE OF REVOCATION OF ELECTION TO BE EXEMPT - REVISED 08-13
WORKERS’ COMPENSATION COMPLIANCE FIELD OFFICES
You can email or fax the completed form to:
Email: WC_EXEMPTION@MYFLORIDACFO.COM
Fax: (850) 354-5100
400 West Robinson Street
2295 Victoria Avenue, Suite 284
Room #512, North Tower
Ft. Myers, FL 33901
Orlando FL 32801-1756
Telephone (239) 461-4006
Telephone (407) 835-4406
401 NW 2
Avenue
nd
600 University Office Boulevard, Suite 15
Suite #318, South Tower
Pensacola FL 32504
Miami FL 33128-1740
Telephone (850) 453-7804
Telephone (305) 536-0306
400 N. Congress Avenue, Suite 105
TALLAHASSEE SUBMITTERS
West Palm Beach FL 33401
Walk-in submissions:
Telephone (561) 837-5716
1579 Summit Lake Drive
Tallahassee FL 32317
1313 N. Tampa Street, Suite # 503
Telephone (850) 413-1609
Tampa FL 33602
Telephone (813) 221-6506
921 North Davis Street
Mail in submissions:
200 East Gaines Street
Building B, Suite #250
Tallahassee FL 32399-4228
Jacksonville, FL 32209
Telephone (850) 413-1609
Telephone (904) 798-5806
DFS-F2-DWC-250-R, NOTICE OF REVOCATION OF ELECTION TO BE EXEMPT - REVISED 08-13
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