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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* 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 SIGNATURE OF EXEMPTION HOLDER DATE SIGNED WORKERS COMPENSATION INF ...

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