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NOTICE OF ELECTION TO BE EXEI\1PT Cf3IJ ",.. 755' ~ STATE USE ONLY Please refer to the written instructions prepared by the Division of \V orkers' Compensation before completing this form. Effective/lssue Date: By filing this application, you elect to be exempt from the provisions of Chapter 440, Florida Statutes and waive any right you may have to workers' compensation benefits in the State of Florida should you become injured on the job. Anv person who knowine:ly and with intent to iniure.' defraud. or deceive the Division or any employer, employee. or insurance company or purposes proe:ram. files a Notice of Election to be Exempt contain in!?: any false or misleadin!?: information is !?:uiltv of a felony of the third de!?:ree. Certain documentation is required by law to be attached to this application-refer to the instruction sheet for more details. I am applying for exemption as a (check only one box in this section): AND EMPLOYMENT SECURllY CONSTRUCTION INDUSTRY ( S 50.00 FEE REQUIRED) ... , \ H Division oj Workers' Compensation ~Sole Proprietor 0 Partner 0 Corporate Officer (your corp. title:~ 9215 N. Flcl-ida 1G~e, Suite 107 NON-CONSTRUCTION INDUSTRY ( NO FEE REQUIRED) Tampa, Florida 33612-7905 o Corporate .Offic'er (your corp, title:' ) CORPORATE OFFICERS AND PARTNERS: List the registration number of your business on file with the Division of Corporations, Department of State' s Office TE:, your partnership may not have one, but all corporations must have one, If your partnership doesn't have one, state "N/A"): THIS EXEMPTION APPLICATION APPLIES ONLY TO THE PERSON SIGr-iING THE APPLICATION AND ONLY FOR THE BUSINESS ENTITY LISTED IN THE FOLLOWING SECTION Business Name: Trade Name; d/b/a; or a/k/a: Lul'( u.s;: G LL Business Mailing Address: " ::; 5/LV - C. count}:p' Phone No.: rq sea (813) Unemploym~nt Compensation , . I No. of Employees: Tax No: N I~ ~,.. 2.- 1<(., ~ 0 I Are you required to be registered or certified pursuant to Chapter 489, F. S.? No IT6Y es: list all certified or registered I licenses issued to you pursuant to Chapter 489, Florida Statues C r:;. C 0 ~ \ ? II . ~ It 00 l055 ) . C --:::- . Are you or a qualifier for yo r business required by the county or the municipality in which your business mailing address is located to have an occupational license for the business which is the subject of this application? 0 No lJ6Yes: I YOU MUST ATTACH A COPY OF A CURRENT OCCUPATIONAL LICENSE' I Are you emBJoyed by any sole proprietorship, partnership, corporation or business entity other than the bus'iness to which this application applies? G'" NO 0 YES list the name of all other businesses in which you are employed: I I Zip: S~4-1 ~ Has the above-referenced business entity been in operation long enough to have filed with or be required to file by the IRS, : an annual Federal Income Tax Return? 0 No !J2fYes, You must attach tax records. See instruction sheet for details. AFFIDAVIT OF APPLICANT: I hereby certify that the information contained herein is true and correct to the best of my knowledge and belief; that this election does not exceed exemption limits for corporate officers or partners as provided in ~~~0.02 Florida Statutes; and that I will secure the payment of workers' compensation benefits, pursuant to Chapter 440, Florida Statutes, for any employee I now have or may hereinafter acquire, for which my business is required by Florida law to secure such benefits, (( U S ~ e CL V\I\ ~ Ololu/J TYPEIl'RI~OF PERSON APPLYli'iG FOR EXDIPTIO:'i -; '-PM M I 9i-O-<.A- APPLICAi'iT'S SIG:'iATURE D NOTARY STATE OF FLORIDA, COUNTY OF u~sc.o .:5'CJ V. / / G /Z-tiXH SOCIAL SECl:RITY NO. J 0 / It bL 0/26100 DATE SIG;';ED mo. day D.A TE OF BIRTH yr. Sworn to and subscribed before me this ..:l7rl.aay of ~,^fC,C:: ~. by Personally Known ~R proglced Ident~ r Type of Identification Produce 00__. -.. ~._.. '_"__ ynAJ.I'.d-i'--1/~