PARTIAL EXAMPLE FORM - NOT TO BE SUBMITTED. OBTAIN FORM FROM YOUR INSURANCE AGENT

CONSTRUCTION INDUSTRY NOTICE OF ELECTION TO
BE EXEMPT FROM THE PROVISIONS OF THE FLORIDA
WORKERS' COMPENSATION LAW

MAIL TO:
Department of Labor & Employment Security Bureau of W.C. Compliance
2728 Centerview Drive, 100 Forrest Bldg.
Tallahassee, Florida 32399-0661

RE:
______________________________________________________________________
(Legal Business Name of Sole Proprietorship, Partnership, or Corporation) (D/B/A If Applicable)

______________________________________________________________________
(Mailing Address) (Street Address, if different)

______________________________________________________________________
(City) (State) (Zip) (Federal Employer Identification Number) (Telephone #)

Nature of Business or Trade:|
______________________________________________________________________

Pursuant to rule 38F-8.009(a), As of 12:01 a.m. 30 days following the date of the mailing of this form, you are hereby notified that the following Sole Proprietor, Partner or Corporate Officer of the above named business does elect to be exempt from the provisions of the Florida Workers' Compensation Law. I understand that by this action I am not entitled to benefits under chapter 440, Florida Statutes. By filing this form I have not exceeded the exemption limit of three Partners or three Corporate Officers. I further certify that any employees of the business named above are covered by workers' compensation insurance.

REQUIREMENT: LIST CERTIFIED OR REGISTERED LICENSES HELD PURSUANT TO CHAPTER 489 FS OR LOCAL OCCUPATIONAL LICENSES.

(1) Type:______________ Number:__________ (2) Type:_________ Number:__________

IMPORTANT: A NON-REFUNDABLE TWENTY FIVE DOLLARS ($25.00) Individual exemption filing fee is required pursuant to Florida statutes 440, and is payable by cashier's check or money order to W.C. Administration Trust Fund. Failure to enclose fee and totally complete this form will result in return of the request and create a delay in certification. Form is valid until specifically revoked.

I,_________________________, sworn under oath, do depose as follows:

1. I maintain a separate business with my own work truck, equipment, materials, or similar accommodation;

2. I hold or have applied for a Federal employer identification number;

3. I perform or agree to perform specific services or work for specific amounts of money and control the means of performing the services or work;

4. I incur the principal expenses related to the service or work that I perform or agree to perform;

5. I am responsible for the satisfactory completion of the work or services that I perform or agree to perform and could be held liable for a failure to complete the work or service;

6. I receive compensation for work or services performed for a commission or on a per job or competitive bid basis and not on any other basis;

7. I may realize a profit or suffer a loss in connection with performing work or services;

8. I have continuing or recurring business liabilities or obligations; and

9. The success or failure of my business depends on the relationship of business receipts to expenditures

Type / print name

Signature of affiant: Social Security Nu

(Only one signature per form)

Position: Owner/proprietor Partner Corporate Officer / Title

NOTARY AREA HERE. THE FORM MUST BE NOTARIZED PROPERLY OR WILL BE RETURNED

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