BCM 250 Notice of Election to be Exempt
Please refer to the written instructions prepared by the Division of Workers' Compensation before completing this form.
By filing this application, you elect to be exempt from the provisions
of chapter 440, Florida Statutes and waive any right you may have
to workers' compensation benefits in the state of Florida should
you become injured on the job. Any person who knowingly and with
intent to injure, defraud, or deceive the Division or any employer,
employee, or insurance company or purposes program, files a Notice
of Election to be Exempt containing any false or misleading information
is guilty of a felony of the third degree.
Please download and complete this form. When completed, please print and send the form to the district office listed below that is closest to your place of business:
2295 Victoria Ave. Suite 163 Ft. Myers, FL 33901 Telephone (239) 461-400 |
921 N. Davis St. Building B, Suite #250 Jacksonville, FL 32209 Telephone (904) 798-580 |
401 NW 2nd Ave. Suite #321 South Tower Miami FL 33128 Telephone (305) 536-030 |
610 E. Burgess Road Pensacola, FL 32504-6320 Telephone (850) 453-780 |
400 West Robinson St. Room #512 North Tower Orlando FL 32801 Telephone (407) 245-089 |
TALLAHSSEE SUBMITTERS |
| 3111 South Dixie Hwy. Suite #123 West Palm Beach FL 33405 Telephone (561) 837-571 |
499 Northwest 70th Avenue Suite #116 Plantation FL 33317 Telephone (954) 321-290 |
Walk-in submissions: 2012 Capital Circle SE Suite #102 Hartman Bldg. Tallahassee FL 32399-2161 Telephone (850) 413-160 |
| 1313 N. Tampa St. Suite #503 Tampa FL 33602 Telephone (813) 221-650 |
Live Oak Business Center 5969 Cattlemen Lane Sarasota FL 34232 Telephone (941) 329-1120 |
Mail in submissions: 200 East Gaines Street Tallahassee FL 32399-4228 Telephone (850) 413-1609 |
| 1111 NE 25 th Ave. Suite #403 Ocala FL 34470 Telephone (352) 401-535 |
TALLAHSSEE SUBMITTERS
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
