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 c....
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How to fill out the FL DWC 250 online
The FL DWC 250 is a critical form for revoking an election to be exempt from workers' compensation coverage. Completing this form online can simplify the process and ensure your information is submitted accurately and efficiently.
Follow the steps to successfully complete the FL DWC 250 online.
- Click 'Get Form' button to obtain the form and open it in your editor.
- Carefully read the section to select your current exemption category. Choose between 'Construction Industry' or 'Non-Construction Industry' by checking the appropriate box.
- For both categories, if you select 'Corporate Officer,' be sure to type your corporate title in the designated field.
- Fill in the corporation or LLC name where prompted, ensuring the name captured is accurate.
- Provide your business mailing address, including county, city, state, and zip code. Make sure all fields are filled in completely to avoid processing delays.
- Enter your phone number, including the area code, in the provided format.
- List your Corporate registration number and Federal Employer Identification Number (FEIN) to ensure proper identification of your business.
- Identify the scope of your business or trade by listing all relevant activities in the spaces provided. Be clear to detail activities that are significant to your operation.
- Document the name of your workers’ compensation insurance carrier covering any non-exempt employees. This is crucial for compliance with state regulations.
- After filling all required fields, review your information for accuracy. Make corrections as needed.
- Type or print your name in the space provided, and ensure you sign the form with the date when submitting.
- Finally, you may save your changes, download, print, or share the form as necessary.
Complete your FL DWC 250 online today for seamless processing of your revocation.
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