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<br />05/05/03 ~os 14:37 FAX 81~94~6670 <br /> <br />PREFFERED-PROPERTIES <br /> <br />@OOl <br /> <br />09-25-2001 <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 t.o be exempt from Florida Workers' <br />Compensation Law. <br /> <br />EFFECTIVE DATE 10/12/2001 <br />EXPIRATION DATE 10/12/2003 <br /> <br />EXEMPTED INDIVIDUAL NAME <br /> <br />KELLY <br />274-64-7737 <br /> <br />ROBERT <br /> <br />A <br /> <br />S.S. <br /> <br />BUSINESS NAME <br /> <br />GOLD MEDALLION HOMES INC <br /> <br />FEIN <br /> <br />593408464 <br /> <br />19909 U 5 41 <br />LUTZ <br /> <br />FL 33549 <br /> <br />BUSINESS ADDRESS <br /> <br />NOTE: PurslIant to Chapter 440.10(1),(9),2 F.S., a sole proprietor, partner, or an officer of a <br />corporation who elects exemption from the Florida Workers' Compensation Law may not recover <br />benefits or compensation under Chapter 440. <br /> <br />PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE <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. 10/121200 1 __ ~.. ~ ~ <br />EXPIRATlCN DATE 10/12/2003 .... <br />EX~PTED PERSON LAST NAME KELLY <br />FIRST NAME Q08ERT A <br />SOCIAL SECURITY NUMBER 274 64 7737 <br />BUSINESS NAME GOLD MEDAlLION HOMES INC <br /> <br /> <br />NOTE: Pursuant to chapter 440.10(1),\g),2, F,5.. a sole <br />proprietor, partner, or officer of a corporetion who <br />elects exemption from the Florida WorkerS' Compensatiol1 <br />Law :nay not recover benefits or compensation under <br />Chapter 440. <br /> <br />FEDERAL IDENTIFICATION NUMBER 593408464 <br />BUSINESS AOORESS 1990~ II S 41 <br /> <br />H <br />E <br />R <br />E <br /> <br />CUT HERE <br /> <br />· Carry bottom portion on the lob, k:eep upper portion for your records. <br />