ACORD 173FL Instructions

ACORD 173 FL (2004/11) – Florida Notice of Election to Be Exempt

Use this form to notify the Florida Department of Labor and EmploymentSecurity, 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 March 2004