ACORD 172 FL (2004/04) – Florida Revocation of Election to be Exempt

Use this form 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 May 2003.