Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 173 FL (2007/08)
Florida Notice of Election to Be
Exempt
Use ACORD 173 FL, Florida Notice of Election to Be Exempt, to notify the Florida
Department of Labor and Employment Security, Bureau of Workers Compensation
Compliance, that a sole proprietor, partner, or corporate officer or a member of a limited
liability company of an eligible business in the construction industry or a corporate officer
of a business in a non-construction industry elects to be exempt from workers
compensation coverage.
Separate forms must be used for each separate individual.
ACORD 173 FL is the same as the Florida Division of Workers' Compensation form DWC
250, Revised October 2006.
APPLICANT
Applicant's Name
Type or print the name of the applicant.
APPLICANT
Applicant's social security number
or individual taxpayer ID
Provide the applicant's social security number or individual taxpayer ID.
APPLICANT
Applicant's e-mail address
Provide the applicant's e-mail address. (optional)
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.
SECTION 3
Document Number
To be eligible for an exemption, the corporation of which you are an officer or the limited
liability company of which you are a member must be registered with the Florida Division
of Corporations. For applicants applying as an officer of a corporation, you must be listed
as an officer of the Corporation with the Florida Division of Corporations. List the
document number (document number shown on your Annual Report) on file with the
Florida Division of Corporations.
CORPORATION
INFORMATION
Name of Corporation or LLC
Provide the name of the Corporation or Limited Liability Company as registered with the
Florida Division of Corporations.
CORPORATION
INFORMATION
FEIN
Provide the federal employer identification number of the organization.
CORPORATION
INFORMATION
Business Name
Provide the business name if applicable. List fictious name; Doing Business As (DBA) or
Also Known As (AKA).
CORPORATION
INFORMATION
Phone
Provide the telephone number of the organization. (Include area code and number)
ACORD 173 FL (2007/08)
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Section Name
Field Name
Field and/or Section Description
CORPORATION
INFORMATION
Business Mailing Address
Provide the business mailing address. Include apartment or suite number.
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
Scope of Business or Trade of
Applicant
Identify the scope of the business or trade of the applicant.
SECTION 5
Certified/Registered Licenses
List all certified or registered licenses issued pursuant to Chapter 489, F.S. held by the
applicant, or the certified or registered license numbers held by the qualifier for the
corporation or LLC listed on this application of which the applicant is a corporate officer:
SECTION 6
Does the county or municipality in
which your business is located
require an occupational license for
your business?
If YES, a copy of the current occupational license must be attached.
SECTION 7
Are you affiliated with any
corporation (including LLC) other
than the corporation (including
LLC) to which this application
applies?
If YES, please list the name(s) and FEIN(s) of the affiliated corporation(s) or LLC(s).
SECTION 7
Name
Provide the name of the affiliated corporation or LLC.
SECTION 7
FEIN
Provide the federal employer identification number of the affiliated corporation or LLC.
FRAUD NOTICE
Signature of Applicant
Applicant must sign the fraud notice.
SECTION 10
Carrier Name
Identify the Workers' Compensation carrier that covers non-exempt employees of your
business.
AFFIDAVIT OF APPLICANT Applicant's Signature
Applicant must sign the affidavit.
AFFIDAVIT OF APPLICANT Date Signed
Indicate the date the affidavit was signed. (MM/DD/YYYY)
AFFIDAVIT OF APPLICANT Notary, State of Florida, County of
Provide the name of the county of the notary.
ACORD 173 FL (2007/08)
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Section Name
Field Name
Field and/or Section Description
AFFIDAVIT OF APPLICANT me this ____ day
Sworn to and subscribed before
Indicate the date applicant appeared before the notary.
AFFIDAVIT OF APPLICANT of
Indicate the month applicant appeared before the notary.
AFFIDAVIT OF APPLICANT
Indicate the year applicant appeared before the notary.
AFFIDAVIT OF APPLICANT by
Print or type the name of the notary.
AFFIDAVIT OF APPLICANT Personally Known
Check this box if the notary personally knows the applicant
AFFIDAVIT OF APPLICANT Produced Identification
Check this box if the the applicant produced identification to the notary.
AFFIDAVIT OF APPLICANT Type of Identification Produced
Indicate the type of identification produced to the notary (e.g., Photo ID, passport).
AFFIDAVIT OF APPLICANT Notary Signature
Notary must sign the form.
AFFIDAVIT OF APPLICANT My commission expires
Indicate the date upon which the notary's commission will expire. (MM/DD/YYYY)
ACORD 173 FL (2007/08)
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