Laserfiche WebLink
<br />07/13/2006 23:23 <br /> <br />7273757332 <br /> <br />NOTICE OF ELEcnON TO BE EXEMPT - Page 2 <br /> <br />PAGE 02 <br /> <br />SECTION 2. You must identify tile workers' compensation insurance carrier <br />business. Carrier Name: <br /> <br /> <br />4-- '~:'.~~~I:.tr.. ,. i$~;' t <br />AFFIDA;VIT OF APPLICANT: I hereby certify that the information contained herein is true and eorreet t~"tliiCbest of my <br />knowledge and belief; that this election docs not exceed exemption limits for corporate officers, including any affiliated <br />corporations as provided in ~440,02 Florida Statutes; and that any non-exempt employees of the corporation or limited liability <br />company (LLC) identified in section 3 of this notice are covered by workers' compensation insurance. <br /> <br /> <br />~~~ / YO I g33~ <br /> <br />SOCIAL Sf'..cuJUTV NUMRER. <br /> <br />7 -L5-0'~ <br /> <br />DATE SIGNED <br /> <br />NOTARY STATE OF FLORIDA, COUNTY OF Hi\\"!:o~c>,.oo\"" <br />~. <br />Swom to and subscribed before me this~ day of :r v \... <br />, <br /> <br />'2.Do," , by J')o.....i~ \ k. A c.\c......._ <br /> <br />Personally Known OR Produced Idcntification~ Type of Identification <br />Produced fc.1:l L ,A)..w ~.f71.4' ')~'-Q <br /> <br />NOTARYSIGNATURBU ~ <br /> <br />My Commission Expires <br /> <br />Plea."le submit this completed form, along with any attachments and a $50.00 <br />BppUcadon fee (construction jndu$tl'y appHc:ants only) payable to the DFS WC <br />Administration Trust Fund, to the District Office Ustcd below that is closest to your <br />place of business. <br /> <br />4415 Metro Parkway '11 N. Davis St. 401 NW 2nd Ave. <br />Suite #300 Building B, Suite #250 Suite #32.1 South Tower <br />Ft. Myers FL 33916 JacksonnIle, FL 3ZZ09 Miami FL 33128 <br />Telephone (239) 938-1840 Telephone (904) 798-5806 Telephone (305) 536-0306 <br />2686 Chapman Dr. 400 West Robiolon St. UlI NE 2.5'" Ave. <br />Panama City FL 32405 Room #111 North Tower Suite #403 <br />Telepbone (850) 747~5425 Orlando FL 32801 Ocala FL 34470 <br /> Telepbone (407) 245--08;6 Telephone (352.) 401-5350 <br />610 E. Burgess Road 499 Northwest 70th Avenae TALLAHASSEE <br />Pensacola, FL 32504-6320 <br />Telepbofte (850) 453-7804 Suite #116 SUBMITTERS <br /> Plantation FL 33317 <br />3111 Sonth Dixie Hwy. Telephone (954) 321-2906 Wlllk-in $Ubmi8~ns: <br />Suite #123 2012 Capital Circle SE <br />West Palm Belich FL 33405 1313 N. Tampa St, Sutte #102 Hartman Bldg. <br />Telephone (561) 837-5716 Saite #51)3 Tallahassee FL 3Z399.2161 <br /> Tampa FL 33602 Telephone (850) 413-1609 <br />1718 Main St. Telephone (813) 211..6506 MIIJI in submissiolJ$: <br />Suite #201 <br />Barasotu FL 34236 200 ERSt Gables Stroot <br />Telephone (941) 329-1120 Tallahassee FL 32399-4228 <br /> Teleph(lne (150) 413.1609 <br /> <br />18..."................".........., <br />ftICHARD M, WOY'; ':.:ICH . <br />_ camrr;.o: OIJC;;38a~3 i <br />~ 7n112OO8 ; <br />. . 8andw thnl (eOO)0432.<l2~! <br />H..~~~~.~.~.&~.~i <br /> <br />:::;1:,:: <br /> <br /> <br />.'-f.: : <br /> <br />'~~~:(J.. '.:.;, <br /> <br />Effcetivc/Issuc Date: <br /> <br />7/13/6& <br /> <br />Expiration zc: <br /> <br />c:! dr. /6 <:( <br />120001tf.oL <br /> <br />Postmark Date: <br /> <br />Received Date: <br /> <br />P-q <br /> <br />JUL 1 $ 'Z.ooa <br />UREAU OF COMPUANCE <br />TAMPA <br /> <br />Payment Number: <br /> <br />DWC 2GO, NOTICE OF ELECTION TO BE EXEMPT - REVtSED :moo4 <br />1V.;! <br /> <br />THIS APPLICATION IS CONTINUED FROM THE REVERSE SIDE <br />