ACORD 172 FL (2007/08)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 172 FL (2007/08)
Florida Revocation of Election to
be Exempt
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.
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.
CONSTRUCTION
Check Box - Member of a Limited
Liability Company
Check this box if applicant is a member of a limited liability company in the construction
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
INFORMATION
Scope of Business or Trade of
Applicant
Identify the scope of the business or trade of the applicant.
CORPORATION
INFORMATION
Carrier Name
Identify the Workers' Compensation carrier that covers non-exempt employees of your
business.
ACORD 172 FL (2007/08)
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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)
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