Section 1: Applicant Information

Applicant Name

First Name:

Middle Initial:

Last Name:

Suffix:

Applicant Government Issued Identification

Type of Identification

VALID State Driver License

Florida ID Card

Issuing State:

VALID Driver's License or Florida ID Number:

Expiration Date (mm/dd/yyyy):

A driver’s license is considered valid provided it has not been expired for more than 30 days at the time of submission of the exemption application. If an application is returned for any reason, the original exemption application submission date will apply when determining if a license is valid.

Click here for information on obtaining a Florida Driver's License or Florida Identification Card.

Applicant Details

Date of Birth (mm/dd/yyyy):

Email Address:

Confirm Email Address:

The Division's purpose in collecting an email address is to communicate with the applicant regarding exemption related issues.

Section 2: Industry

Please select the correct ownership type (Officer of a Corporation or Member of a Limited Liability Company). This selection must coincide with your document number in Section 4 of the application.

CONSTRUCTION INDUSTRY APPLICANT ($50 FEE REQUIRED)

Officer of a Corporation - The applicant must own a minimum of 10 percent of the corporation.

Member of a Limited Liability Company (LLC) - The applicant must own a minimum of 10 percent of the LLC.

NON-CONSTRUCTION INDUSTRY APPLICANT

Officer of a Corporation - The applicant of the non-construction industry corporation does not require 10 percent ownership.

Member of a Limited Liability Company (LLC) - The applicant must own a minimum of 10 percent of the LLC.

Section 3: Company Information

This section should be completed with information specific to your corporation or to the limited liability company in which you are a member. The name of the corporation or limited liability company listed on this application MUST match the name of the corporation or limited liability company as registered with the Florida Division of Corporations. If you are unsure of the registered name, Click here to search the Florida Division of Corporations’ corporate records. You may copy and paste the company name and document number.

Note: The corporation or limited liability company must be REGISTERED and listed as ACTIVE with the Florida Department of State, Division of Corporations. A Fictitious Name Registration does not satisfy Workers’ Compensation Exemption requirements. An ANNUAL report MUST be filed with the Department of State, Division of Corporations each year for your business entity to maintain an "active status" with the Department of State. For additional information, go to https://dos.myflorida.com/sunbiz/manage-business/efile/annual-report/.

Company Details

Corporation/LLC Name:

FEIN ##-#######:

Business Name (DBA):

Phone (###) ###-####:

Street Address:

Zip Code:

City: State: County:

Section 4: Division of Corporations Document Number

Please check your selection in Section 2 of the application to ensure you have selected the correct ownership type or your document number will not be accepted.

Document Number

Document Number on file with the Florida Division of Corporations:

You may copy and paste the document number.

Section 5: Department of Business & Professional Regulation License

DBPR License

DBPR License Number:

Additional DBPR License Number:

This section is not applicable to my business.

Section 6: Confirmation Number

Confirmation Number

Confirmation Number:

(confirmation number will appear on completed application after successful payment)

Section 7: Company Affiliations

Affiliation

Are you affiliated with any corporation or limited liability company other than the corporation or limited liability company to which this application applies?

Yes

Name:

FEIN ##-#######:

Name:

FEIN ##-#######:

Name:

FEIN ##-#######:

Section 8: Construction Industry and Non-Construction Industry Limited Liability Company (LLC) Members Only

Percentage of Ownership

To be eligible for a construction industry exemption or non-construction limited liability company exemption, an applicant must have the required ownership of the corporation or limited liability company (LLC).

I have at least 10% ownership of the corporation or limited liability company (LLC) listed on this application.

Section 9: Workers' Compensation Insurance Carrier

Insurance Carrier Information

Please complete one of the sections below.

I certify that:

any employees of the construction corporation or limited liability company; or
four or more part or full-time employees of the non-construction corporation or limited liability company (LLC)

listed in Section 3 are covered by workers' compensation insurance. Please identify the workers' compensation insurance carrier that covers any non-exempt employees.

Carrier Name:

- My business does not have any non-exempt employees; or, my business is not required to obtain workers' compensation.

Section 10: Fraud Notice

Fraud Notice Statement You must attest to all elements of the Fraud Notice by checking the boxes below.

Any person who, knowingly and with intent to injure, defraud, or deceive the department or any employer or employee, insurance company or any other person, files a Notice of Election to be Exempt containing any false or misleading information is guilty of a felony of the third degree.

Attestation of applicant – By providing my name below, I attest that I have read, understand and acknowledge the foregoing notice.

I acknowledge that this Notice of Election to be Exempt does not exceed limits for corporate officers, including any affiliated corporations as provided in Section 440.02, Florida Statutes.

Important: Any person other than the applicant attesting to the notice may be guilty of a felony of the third degree.

I certify I reviewed and understand the workers’ compensation coverage and compliance tutorial developed by the department.

I understand that the Division of Workers’ Compensation must assess an exemption fee of $50 plus a convenience fee of $1.00 with each request for a construction industry Certificate of Election to be Exempt or renewal of a Certificate.

It is the responsibility of the exemption holder to notify the Department of any changes to their personal information such as their address or e-mail address listed on the certificate, the dissolution or reinstatement of the corporation or limited liability company listed on the certificate, or when the person named on the certificate is no longer a corporate officer or member of the corporation or limited liability company listed on the certificate. Failure to notify the Department of any such changes, may result in a lapse of exempt status or additional expenses to the exemption holder.

First Name:

Last Name:

VALID Driver's License or Florida ID Number:

Exemption information is reflected on the Exemption Search database the day following the issuance of the exemption.

NOTE: Please review the application prior to clicking the Next button.
You will not have access to modify your application after you click Next.

P02 Updated: 04/26/2023

NOTICE OF ELECTION TO BE EXEMPT

Section 1: Applicant Information

Section 2: Industry

Section 3: Company Information

Section 4: Division of Corporations Document Number

Section 5: Department of Business & Professional Regulation License

Section 6: Confirmation Number

Section 7: Company Affiliations

Section 8: Construction Industry and Non-Construction Industry Limited Liability Company (LLC) Members Only

Section 9: Workers' Compensation Insurance Carrier

Section 10: Fraud Notice