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 Name of Exemption Holder you wish to revoke:
First Name

Last Name

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)

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:

Exemption Address of record

Street:

Zip Code:

City:

State:

County:

FEIN: ######### (9 digits no dashes)

Phone Number: ###-###-####

Document Number on file with the Division of Corporations:

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

Email Address:

Click here for the DWC Exemption website

NOTICE OF ELECTION TO BE EXEMPT