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<br />08-01-2000 <br /> <br />STATE OF FLORIDA <br />DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY <br />DIVISION OF WORKERS' COMPENSATION <br /> <br />CONSTRUCTION INDUSTRY CERTIFICATE OF EXEMPTION <br />FROM FLORIDA WORKERS' COMPENSATION LAW <br /> <br />This certifies that the individual listed below has elected to be exempt from Florida Workers' <br />Compensation LIIW. <br /> <br />EFFECTIVE DATE 07/22/2000 <br />EXPIRATION DATE 07/22/2002 <br /> <br />EXEMPTED INDIVIDUAL NAME <br /> <br />LAUINGER <br /> <br />JOHN <br /> <br />C <br /> <br />S.S. <br /> <br />131-36-7279 <br /> <br />BUSINESS NAME <br /> <br />MIRBEC INC <br /> <br />FEIN <br /> <br />593613190 <br /> <br />BUSINESS ADDRESS <br /> <br />4400 COUNTY BREEZE DRIVE <br />NEW PORT RICHEY <br /> <br />FL 34653 <br /> <br />NOTE: Pursuant to Chapter 44tO.10(1),(g),2 F.S.. a sole proprietor. partner, or an officer of. <br />corporation who elects exemption from the Florida Workers' Compensation Law may not recover <br />benefits or compensation under Chapter 440. <br /> <br />STATE OF FLORIDA <br />DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY <br />DIVISION Of WORKERS' COMPENSATION <br /> <br />CONSTRUCTION INDUSTRY CERTIFICATE OF EXEMPTION <br />FROM FLORIDA WORKERS' COMPENSATION LAW <br />EFFECTIVE DATE 07/12/2000 <br />EXPIRATION DATE 07/22/2002 <br />EXEMPTED PERSON LAST NAME lAIII~GER <br />fiRST NAME 'OWN C <br />SOCIAL SECURITY NUMBER 13 1- 3 6 7279 <br />BUSINESS NAME MIRBEC 'NC <br /> <br />PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE <br /> <br /> <br />NOTE: Pursuent to chapter 440.1 0(1l,(g),2, F.S., a sole <br />proprietor, pert"er, or off icer 0 f a corporation who <br />elects exemption from the Florida WorKers' Compensation <br />law may not recover benef its or compensation under <br />Chapter 440. <br /> <br />FEDERAL IDENTIFICATION NUMBER 593613190 <br />BUSINESS ADDRESS 4400 COllNTY BR!:EZE DRI~ <br /> <br />H <br />E <br />R <br />E <br /> <br /> <br />CUT HERE <br /> <br />* C..ry bottom portion on the job. keep upper portion for your r.cords. <br />