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<br />~,~~ -~!J <br />~~.. <br />STATE OF FLORIDA <br />DEPARTMENT OF FINANCIAL SERVICES <br />DIVISION OF WORKERS' COMPENSATION <br />* * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW <br />CONSTRUCTION INDUSTRY EXEMPTION <br /> <br /> <br />06-18-2007 <br /> <br />ALEX SINK <br />CHIEF FINANCIAL OFFICER <br /> <br />* * <br /> <br />This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. <br /> <br />EFFECTIVE DATE: <br /> <br />06/18/2007 <br /> <br />EXPIRATION DATE: 06/17/2009 <br />LAVERNE C <br /> <br />PERSON: FO~ER <br /> <br />FEIN: 204567523 <br /> <br />BUSINESS NAME AND ADDRESS: <br />TKoJ CONSTRUCTION COMPANY INC <br />37606 MARCLIFF TERRACE <br />ZEPHYRHILLS FL 33541 <br /> <br />SCOPES OF BUSINESS OR TRADE: <br />1- CERTIFIED ROOFING CONTRACTOR <br /> <br />IMPORTANT: Pursuanl 10 Chapler 440 . 05(141, F.S., an officer of a corporalion who elects exe.plion from Ihls chapler by flliag a certlficale of eleclion under Ihis <br />section may nol recover benefits or compensalion uDder Ihls chapler. Plrsuant 10 Chapler 440.05(111, F.S., Certlflclles of eleclion 10 be exempL.. apply only wilhin Ihe <br />scope of the business or UNe Iislod on Ihe nolice 01 e/eclion to be exempL Pursuanl 10 Chapler 440.051131, F.S., Notices of oloction 10 be exnmpl ad cortificllOS of <br />eleclion 10 be exempl shall be sublecl 10. revocllion ii, al sny time aller the Iiling of Ihe nolice or the issuance of Ihe certificale, the person na.ed on llIe nolice or <br />certiliclle no longor meels Ihe requiromenls 01. Ihis seclion for issaloce 01 a certllicate. The dopnrtmenl shall revoke a certificale al any Ii.e fnr Ililure nf the person <br />nlmed on Ihe certilicale 10 lReel Ihe. requiremenls 01 this seclion. <br /> <br />aUESTIONS? (8501 413-1609 <br /> <br />VC-Z5Z CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09-06 <br />