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•�ae tea ' <br /> JIMMY PATRONIS <br /> CHIEF FINANICAL OFFICER STATE OF FLORIDA <br /> DEPARTMENT OF FINANCIAL SERVICES <br /> DIVISION OF WORKERS'COMPENSATION <br /> **CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW <br /> CONSTRUCTION INDUSTRY EXEMPTION <br /> This certifies that-the individual listed below has elected to be exempt from Florida Workers'Compensation law. <br /> EFFECTIVE DATE: 2/26/2019 EXPIRATION DATE: 2125/2021 <br /> PERSON: JENNIFER KOLODZIEJ EMAIL: MYROOFERDAN@GMAIL.COM <br /> FEIN: 264242664 <br /> BUSINESS NAME AND ADDRESS: <br /> MY ROOFER, LLC <br /> 11804 PINE FOREST'DRIVE <br /> NEW PORT RICHEY, FL 34654 <br /> SCOPE OF BUSINESS OR TRADE: <br /> Licensed Roofing Contractor <br /> IMPORTANT:Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exemption from this chapter by filing a certificate of election under <br /> this section may not recover benefits or compensation under this chapter.Pursuant to Chapter 440.05(12),F.S.,Certificates of election to be exempt...apply <br /> only within the scrape of the business or trade listed on the notice of election to be exempt.Pursuant to Chapter 440.05(13),F.S.,Notices of election to be <br /> exempt and certificates of election to be exempt shall be subject to revocation if,at any time after the filing of the notice or the issuance of the certificate,the <br /> person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate.The department shall revoke a <br /> certificate at any time for failure of the person named on the certificate to meet the requirements of this section. <br /> DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609 <br />