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ACORD Form 172 FL Florida Revocation of Election to be Exempt Instructions
 

 
Section Name Field Name Field and/or Section Description
Use ACORD 172 FL, Florida Revocation of Election to be Exempt, to notify the Florida Division of Workers Compensation, Bureau of Workers Compensation Compliance, that an individual who previously submitted a notice of election to be exempt from Workers' Compensation coverage now intends to revoke the exemption.
TITLE ACORD 172 FL (2007/08) Florida Revocation of Election to be Exempt ACORD 172 FL is the same as the Florida Division of Workers' Compensation form DWC 250-R Revised September 2006.
CONSTRUCTION Check Box - Corporate Officer Check this box if applicant is a corporate officer in the construction industry.
CONSTRUCTION Your Corporate Title Provide the applicant's title in the business.
Check Box - Member of a Limited Check this box if applicant is a member of a limited liability company in the construction
CONSTRUCTION Liability Company industry.
NON-CONSTRUCTION Check Box - Corporate Officer Check this box if applicant is a corporate officer in a non-construction industry.
NON-CONSTRUCTION Your Corporate Title Provide the applicant's title in the business.
CORPORATION
INFORMATION Corporation or LLC Name Provide the name of the Corporation or Limited Liability Company.
CORPORATION
INFORMATION Business Mailing Address Provide the mailing address of the organization.
CORPORATION
INFORMATION City Provide the city of the organization.
CORPORATION
INFORMATION State Provide the state of the organization.
CORPORATION
INFORMATION Zip Code Provide the zip code of the organization.
CORPORATION
INFORMATION County Provide the county of the organization.
CORPORATION
INFORMATION Phone Number Provide the telephone number of the organization. (Include area code and number)
CORPORATION
INFORMATION FEIN Provide the federal employer identification number of the organization.
CORPORATION
INFORMATION Corporate Registration Number Provide the corporate registration number of the organization.
CORPORATION Scope of Business or Trade of
INFORMATION Applicant Identify the scope of the business or trade of the applicant.
CORPORATION Identify the Workers' Compensation carrier that covers non-exempt employees of your
INFORMATION Carrier Name business.

ACORD 172 FL (2007/08) 1 of 2 ACORD 172 FL (2007/08) 2 of 2

Section Name Field Name Field and/or Section Description
SIGNATURE Type/Print Name of Exemption Holder Type or print the name of the exemption holder.
SIGNATURE Social Security Number Provide the social security number of the exemption holder.
SIGNATURE Signature of Exemption Holder Exemption holder must sign the form.
SIGNATURE Date Signed Indicate the date the form was completed. (MM/DD/YYYY)