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<br />CONSTRUCTION INDUSTRY
<br />
<br />NOTICE OF ELECTION TO BE EXEMPT FROM
<br />THE PROVISIONS OF THE F~ORIDA WORKERS' COMPENSATION LAW
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<br />MAIL TO: Department of Labor & Employment Security
<br />Bureau of W.e. Compliance
<br />2728 Centerview Drive, 100 Forrest Bldg.
<br />Tallahassee, Florida 32399-0661
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<br />STATE USE ONLY
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<br />POSTMARK DATE
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<br />
<br />I~
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<br />PLEASE TYPE OR PRINT:
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<br />This noticc shall be in effect tllr Iwo (2) years from the
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<br />dkctive date of] - ;Jf)-q ( unli-;-r... ;26-'1~,
<br />or until revoked, whichever comes firsl.
<br />
<br />RE:
<br />
<br />
<br />~.~~/2n1t
<br />V (~tng Address)
<br />
<br />J!AO.- LL-7' .,et. --J.jS:~- ~~~~839a
<br />'ity) (State) (Zip) (Federal Ll1lployer Identification Numhen
<br />
<br />
<br />Nature of Business or Trade: ;C.?E: P9L.JIP~I'A/'T .f)~A.L~-X
<br />
<br />(D/B/A [I' Applieahk)
<br />
<br />/Z hW,1l:.F/l/CI!. ~D_
<br />(Stn.'L't~ddn:ss. if dilkn.'lltl
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<br />As of 12:01 a.m. 30 days following the date of the mailing of this form, you are hereby notified that the following Sole Proprietor,
<br />Partner or Corporate Ofllcer of the above named business does elect to be exempt from the provisions of the Florida Workers'
<br />Compensation Law. I understand that by this action I am not entitled to benetits under chapter 440, Florida Statutes, By filing this
<br />form I have not exceeded the exemption limit of three Partners or three Corporate Officers. I fUlther celtity that any employees of the
<br />business named above are covered by workers' compensation insurance,
<br />
<br />The following are the certified or registered licenses held by me pursuant to chapter 489 Florida Statutes (If none, so state):
<br />(I) Type: esr 07 Numbef'07t)9S"JDOOJ~;> (2) Type: 11'/ Number:O.l."''''9i.ot')l''lJ~1D
<br />
<br />INSURANCE CARRIER INFORMATION (If Applicable): A construction industry employer with one (I) or more employees must
<br />maintain Workers' Compensation coverage, Failure to comply will result in a lIve-hundred dollar ($500) fine and a one-hundred
<br />dollar ($100) fine for each day of noncompliance (see section 440.43, FS,),
<br />
<br />Name of Carrier
<br />
<br />Carrier Address
<br />
<br />Policy Number
<br />
<br />_EI'FEC]'IVE DATE
<br />
<br />Insurance Agent (Agency)
<br />Agency Address
<br />
<br />Signature ./ ~~ . Su,i,,' S,,,,,i.y Numb" OS""'-'I~-08:Y?
<br />
<br />Type/~ame Jfi'y~' gxow.!</'. --~--
<br />
<br />Position: Proprietor ~/Partner _lor/Office; CTitk'i .(}:II.1./Ja'Ji'---
<br />
<br />IMPORTANT: Individual exemption filing fe€, pursuant to Section 440.05, F.S" is seven dollars and fifty cents ($7.50) and is
<br />payable only by money order or cashier's check" to W,(:',:Admi!listrative Truet Fund. Failure 10 enclose fee will result in return of
<br />request and delay of certification,
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<br />SWORN T~AN~ S~BSCRIBED BEFORE ME THIS
<br />
<br />AT A~() L( eet;:;, , FLORIDA.. '" _
<br />? t,u~/RY ..F'U~~~;r. ~ "jlr~ ~ r ..
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<br />U'.J.\ 'cu ',' 1,'.1 . ~-, 'rl"'.Il1 . . ::>'7,
<br />"'" ',L.C,;,.-,. 1.1.:5_ ;'I.;f~
<br />
<br />DAY OF
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<br />
<br />Notary Public. State of Florida
<br />My Commission Ex.pires:
<br />
<br />LES FORM BCM-204 (517191)
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