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State Use Only Revocation of Election of Coverage Form

Q: What is the STATE USE ONLY REVOCATION OF ELECTION OF COVERAGE form?

The STATE USE ONLY REVOCATION OF ELECTION OF COVERAGE form allows individuals to formally revoke their election for coverage under government programs. Using airSlate SignNow, you can easily complete and eSign this document online, ensuring a streamlined and efficient process.

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State use only revocation of election of coverage form

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Workers’ Compensation Information Online - http://www.fldfs.com/WC/ DWC 250-R Revised September 2006 \ TV-3 NOTICE OF REVOCATION OF ELECTION TO BE EXEMPT \ STATE USE ONLY Effective/Issue Date: ________________________________ Control Number: ________________________________ Postmark Date: ________________________________ Received Date: PLEASE TYPE OR PRINT I hereby revoke the exemption I currently have as a (check only one box in this section): CONSTRUCTION INDUSTRY Corporate Officer (your corporate title: ____________________) Member of Limited Liability Company -OR- NON-CONSTRUCTION INDUSTRY Corporate Officer (your corporate title: ____________________) 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) FLOR IDA 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 SOCIAL SECURITY NUMBER _______________________________________________________________ ______________________________________________ SIGNATURE OF EXEMPTION HOLDER \ DATE SIGNED SUBMIT THIS FORM TO THE DISTRICT OFFICE LISTED BELOW THAT IS CLOSEST TO YOUR PLACE OF BUSINESS: WORKERS’ COMPENSATION COMPLIANCE FIELD OFFICES 1111 NE 25 th Ave. Suite #403 Ocala FL 34470 4415 Metro Parkway Suite #300 Ft. Myers FL 33916 Workers’ Compensation Information Online - http://www.fldfs.com/WC/ DWC 250-R Revised September 2006 \ TV-3 Telephone (239) 938-1840 3111 South Dixie Hwy. Suite #123 West Palm Beach FL 33405 Telephone (561) 837-5716 1718 Main St. Suite #201 Sarasota FL 34236 Telephone (941) 329-1120 401 NW 2nd Ave. Suite S-321 Miami FL 33128-1740 Telephone (305) 536-0306 921 N. Davis St. Building B, Suite #250 Jacksonville, FL 32209 Telephone (904) 798-5806 1313 North Tampa Street Suite #503 Tampa FL 33602 Telephone (813) 221-6506 499 Northwest 70 th Avenue Suite #116 Plantation FL 33317 Telephone (954) 321-2906 400 West Robinson St. North Tower, Suite N512 Orlando FL 32801-1756 Telephone (407) 245-0896 or (407) 835-4406 Telephone (352) 401-5350 610 E. Burgess Road Pensacola, FL 32504-6320 Telephone (850) 453-7804 T ALLAHASSEE: Walk-in submissions 2012 Capital Circle SE Suite #102 Hartman Bldg. Tallahassee FL 32399-2161 Telephone (850) 413-1609 Mail in submissions 200 East Gaines Street Tallahassee FL 32399-4228 Telephone (850) 413-1609

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State use only revocation of election of coverage irs

State use only revocation of election of coverage texas

IRS Section 125 permitted election changes

IRS Section 125 qualifying event Checklist

Section 125 qualifying events to drop coverage

26 cfr § 1.125-4 - permitted election changes

IRS qualifying life event 30 days

section 9801(f)

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Fill and Sign the State Use Only Revocation of Election of Coverage Form