Form Dwc 250 R PDF Details

The DWC 250-R form plays a crucial role for those involved in the construction and non-construction industries who previously elected to be exempt from workers' compensation coverage but now wish to revoke this exemption. This official revocation document must be filled out with care, specifying whether the individual revoking the exemption is a corporate officer or a member of a limited liability company. The form requires detailed information, including the effective date of revocation, control number, and specifics about the corporation or LLC, such as its name, business mailing address, scope of business, and workers' compensation insurance carrier for non-exempt employees. Important to note is the requirement under Section 440.05 (3) of the Florida Statutes, mandating officers who are subcontractors to notify their contractors upon exemption revocation, and likewise, the department must inform the identified workers’ compensation carrier(s). Filled with precise details and carrying significant legal implications, the DWC 250-R form is a key document that affects the rights and responsibilities of those in the construction and non-construction sectors, signaling a shift in their workers' compensation coverage stance.

QuestionAnswer
Form NameForm Dwc 250 R
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesFLORIDA, revocation of election to be exempt, 2nd, online

Form Preview Example

STATE USE ONLY

NOTICE OF REVOCATION OF ELECTION TO BE EXEMPT

PLEASE TYPE OR PRINT

Effective/Issue Date:

________________________________

Control Number:

________________________________

Postmark Date:

________________________________

Received Date:

I hereby revoke the exemption I currently have as a (check only one box in this section):

CONSTRUCTION INDUSTRY

Corporate Officer (your corporate title: ____________________)

NON-CONSTRUCTION INDUSTRY

Corporate Officer (your corporate title: ____________________)

Member of Limited Liability Company -OR-

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:

City:

State:

Zip:

County:

Phone No.:

()

FEIN:

Corporate registration number:

Scope of Business or Trade of Applicant Listed on Notice of Election to be Exempt:

1. ______________________ 2. ________________________ 3. ________________________ 4. _____________________

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.

_____________________________________________________________________________________________________________________

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:

WORKERS’ COMPENSATION COMPLIANCE FIELD OFFICES

2295 Victoria Avenue, Suite 163

921 North Davis Street

499 Northwest 70th Ave., Suite #

Ft. Myers, FL 33901

Building B, Suite #250

116

Telephone (239) 461-4006

Jacksonville, FL 32209

Plantation FL 33317

 

Telephone (904) 798-5806

Telephone (954) 321-2906

610 E. Burgess Road

400 West Robinson Street

 

Pensacola, FL 32504-6320

TALLAHASSEE SUBMITTERS

Room #512, North Tower

Telephone (850) 453-7804

 

Orlando FL 32801

WALK-IN SUBMISSIONS:

 

3111 S. Dixie Highway, Suite # 123

Telephone (407) 835-4406

2012 Capital Circle SE

 

Suite #102, Hartman Bldg.

West Palm Beach FL 33405

 

401 NW 2nd Avenue

Tallahassee FL 32399-2161

Telephone (561) 837-5716

Suite #321, South Tower

Telephone (850) 413-1609

 

1313 N. Tampa Street, Suite # 503

Miami FL 33128

MAIL IN SUBMISSIONS:

Telephone (305) 536-0306

Tampa FL 33602

200 East Gaines Street

 

Telephone (813) 221-6506

 

 

Tallahassee FL 32399-4228

 

 

 

 

Telephone (850) 413-1609

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.

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250 conclusion process explained (step 1)

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Guidelines on how to prepare 250 stage 2

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