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Myfloridacfo. com/wc DWC 250-R NOTICE OF REVOCATION OF ELECTION TO BE EXEMPT - REVISED 11/11 RULE 69L-6. 009 F.A. C. SUBMIT THIS FORM TO THE DISTRICT OFFICE LISTED BELOW THAT IS CLOSEST TO YOUR PLACE OF BUSINESS 2295 Victoria Avenue Suite 163 Ft. STATE USE ONLY Effective/Issue Date NOTICE OF REVOCATION OF ELECTION TO BE EXEMPT Control Number Postmark Date Received Date PLEASE TYPE OR PRINT I hereby revoke the exemption I currently have as a check only one box in this section CONSTRUCTION INDUSTRY Corporate Officer your corporate title Member of Limited Liability Company -OR- NON-CONSTRUCTION INDUSTRY THIS REVOCATION OF ELECTION TO BE EXEMPT APPLIES ONLY TO THE PERSON SIGNING THE REVOCATION AND ONLY TO THE CORPORATION/LLC THAT IS LISTED IN THE FOLLOWING SECTION Corporation or LLC Name Business Mailing Address County City Phone No* State FEIN Zip Corporate registration number Scope of Business or Trade of Applicant Listed on Notice of Election to be Exempt 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* ELECTION OF EXEMPTION BY THE DEPARTMENT THE DEPARTMENT SHALL NOTIFY THE WORKERS COMPENSATION CARRIER S IDENTIFIED IN THE REQUEST FOR EXEMPTION* TYPE/PRINT NAME OF EXEMPTION HOLDER SIGNATURE OF EXEMPTION HOLDER DATE SIGNED WORKERS COMPENSATION INFORMATION ONLINE - http //www. myfloridacfo. com/wc DWC 250-R NOTICE OF REVOCATION OF ELECTION TO BE EXEMPT - REVISED 11/11 RULE 69L-6. 009 F*A. C. SUBMIT THIS FORM TO THE DISTRICT OFFICE LISTED BELOW THAT IS CLOSEST TO YOUR PLACE OF BUSINESS 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 499 Northwest 70th Ave. Suite Plantation FL 33317 Telephone 954 321-2906 400 West Robinson Street Room 512 North Tower Orlando FL 32801 Telephone 407 835-4406 TALLAHASSEE SUBMITTERS 401 NW 2nd Avenue Suite 321 South Tower Miami FL 33128 Telephone 305 536-0306 Walk-in submissions 2012 Capital Circle SE Suite 102 Hartman Bldg. STATE USE ONLY Effective/Issue Date NOTICE OF REVOCATION OF ELECTION TO BE EXEMPT Control Number Postmark Date Received Date PLEASE TYPE OR PRINT I hereby revoke the exemption I currently have as a check only one box in this section CONSTRUCTION INDUSTRY Corporate Officer your corporate title Member of Limited Liability Company -OR- NON-CONSTRUCTION INDUSTRY THIS REVOCATION OF ELECTION TO BE EXEMPT APPLIES ONLY TO THE PERSON SIGNING THE REVOCATION AND ONLY TO THE CORPORATION/LLC THAT IS LISTED IN THE FOLLOWING SECTION Corporation or LLC Name Business Mailing Address County City Phone No* State FEIN Zip Corporate registration number Scope of Business or Trade of Applicant Listed on Notice of Election to be Exempt 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* ELECTION OF EXEMPTION BY THE DEPARTMENT THE DEPARTMENT SHALL NOTIFY THE WORKERS COMPENSATION CARRIER S IDENTIFIED IN THE REQUEST FOR EXEMPTION* TYPE/PRINT NAME OF EXEMPTION HOLDER SIGNATURE OF EXEMPTION HOLDER DATE SIGNED WORKERS COMPENSATION INFORMATION ONLINE - http //www. .