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<br />I ...- <br />.... - <br /> <br />CONSTRUCTION INDUSTRY <br /> <br />NOTICE OF ELECTION TO BE EXEMPT FROM <br /> <br />THE PROVISIONS OF THE FLORIDA WORKERS' COMPENSATION LAW <br />EFFECTIVE <br />t.;~, ' , -- -E STATE USE ONLY <br />MAIL TO: Department of Labor & Employment Secutity" ,~.-;':''''':'.i D TO <br />Bureau ofW.C. Compliance C.' <br />2728 Centerview Drive, 100 Forrest Bldg. 0 . <br />Tallahassee, Florida 32399-0661 J'... <br /> <br />-.-------..-- <br /> <br />POSTMARK DATE <br /> <br /> <br />/~ <br /> <br />PLEASE TYPE OR PRINT: <br /> <br />This notice shall be in effect for two (2) years from the <br /> <br />effective date of 1 ~ ,;u)~ ( unti0- ;26-'15. <br />or until revoked, whichever comes first. <br /> <br />RE:~~c:.V~~~"" C:.puJP~~..y r- <br />(Lo;gal Business Na e of ~ole PropriNorship, Plirtnership, or Corporation) <br /> <br />iP~.&~ /2~1t <br />0/ (Mailing Address) <br /> <br />l?~.- ~ <br />ity) (State) <br /> <br /> <br />Nature of Business or Trade: ~~ <br /> <br />~. <br /> <br />(D/B/A If Applicable) <br /> <br />/2 ~1AJ.lZ.~/l/c.6. ~D_ <br />(Street'Address, if different) <br /> <br />?.$S-~S- <br />-(Zip) <br /> <br />~,- Z s-<J 83Cj\ C <br />(Federal Employer Identification Number) <br /> <br />..c9llJPA?~A/T /)~.ALk-.R <br />-- <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 Officer 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 benefits 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 further certify 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 />(1) Type: e:tr Cl7 Number'07t)~-IOOO 187 (2) Type: ()? Number:OZ."I&.q"Ot"')l'\J5l~ <br /> <br />INSURANCE CARRIER INFORMATION (If Applicable): A construction industry employer with one (1) or more employees must <br />maintain Workers' Compensation coverage. Failure to comply will result in a five-hundred dollar ($500) fine and a one-hundred <br />dollar ($100) fine for each day of noncompliance (see section 440.43, ES.). <br /> <br />Name of Carrier <br /> <br />Carrier Address <br /> <br />Policy Number <br />Insurance Agent (Agency) <br />Agency Address <br /> <br />EFFECTIVE DATE <br /> <br />Signature ./ ~~ Social Security Number O~&'-~7'-CJgy9' <br />Type/~ame '_~/ ~. gKOIL/...v' <br />Position: Proprietor -~:::::::'tPartner _/or/Offic!":r I Ti1lp.) 0:* J..4tRJi'_ <br /> <br />IMPORTANT: Individual exemption filing fe~, pursuant to Section 440.05, ES., is seven dollars and fifty cents ($7.50) and is <br />payable only by money order or cashier's check. to W.C. -Administrative Tru"t Fund. Failure to enclose fee will result in return of <br />request and delay of certification. <br /> <br />SWOR~ T~~AN2 8~BSCRIBED BEFORE ME THIS <br />AT JJ.l.tLti:.( e:7- ' FLORIDA .~_ . <br />. /, f,"}','RYll'-'-. <br />/ ~a' 'i:~~'~j[X:~~~;~~'rc: .O~ n.m}OA <br />"'~:."'- ..... 4 -. , ....".. r1:.!I. 11 7""5 <br />l.1V..l.eD ,hl\'j ,"-':ro At I' "::>::7 <br />:t_.~_,..._. f.;s.. liNe.. <br /> <br />I' #. <br />'1'- <br /> <br />/' <br />DAY OF j-a--?o..A- <br />/ , <br />1/. ~ .., j' <br />~ /~. '/ <br />/ d~>!"L.~~.~ /~k~'-t::/(_I- <br /> <br />,. Notary Pldrffc. State of Honda <br />My Conimission Expires: <br /> <br />It.( {j / <br /> <br />LES FORM BCM-204 (5/7/91) <br />