This online application is to REVOKE a current Certificate of Election to be Exempt from Florida Workers’ Compensation Law (exemption).
If you are wanting to exclude an officer of a corporation or a member of a limited liability company from the workers' compensation insurance laws, click here for more information on Exemptions. www.myfloridacfo.com/division/wc/employer/exemptions

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.

Enter the first and last name of the officer or member of LLC as printed on the Certificate of Election to be Exempt from Workers’ Compensation Law (exemption).
The name on the revocation form must be the same as the Certificate holder.
First Name
First Name is Required
Last Name
Last Name is Required

Company Details I hereby revoke the exemption as a

Construction - Officer of a Corporation.

Construction - Member of a Limited Liability Company (LLC)

Non Construction - Officer of a Corporation.

Non-construction - Member of a Limited Liability Company (LLC)

Required

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 LLC Company Name:
Business is Required

Exemption Address of record

Street: Street is Required

Zip Code:

ZipCode is Required

City:

State:

County:

FEIN: ######### (9 digits no dashes)
FEIN Must Be 9 digits FEIN is Required

Phone Number: ###-###-####
Phone Number Must Be Valid Phone Number is Required

Document Number on file with the Division of Corporations:

DocNumber is Required

You must identify and enter the current workers’ compensation insurance carrier that covers any non-exempt employees of your business.

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 WRITTEN REQUEST FROM A WORKERS’ COMPENSATION CARRIER, THE DEPARTMENT SHALL SEND THEREAFTER AN ELECTRONIC NOTIFICATION TO THE CARRIER IDENTIFYING EACH OF ITS POLICYHOLDERS FOR WHICH A NOTICE OF REVOCATION TO BE EXEMPT HAS BEEN RECEIVED.

Name of Individual Requesting this Revocation
	Name is Required
Email Address:
	Email Must Be Valid

Email is Required

Click here for the DWC Exemption website

NOTICE OF ELECTION TO BE EXEMPT