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<br />:s I A I t: Uf' FLUKIUA <br />DEPARTMENT OF FINANCIAL SERVICES <br />DIVISION OF WORKERS' COMPENSATION <br />CONSTRUCTION INDUSTRY <br />CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA <br />WORKE~S' COMP~NSATION LAW <br /> <br />EFFECTIVE: <br /> <br />PERSON: <br /> <br /> <br />F <br />o <br />L <br />D <br /> <br />H <br />E <br />R <br />E <br /> <br />CUT HERE <br /> <br />IMPORT ANT <br /> <br />Pursuant to Chapter 440.05(14), F.S.. an officer of a <br />corporation who elects exemption from this chapter by filing a <br />certificate of election under this section may not recover <br />benefits or compensation under this chapter. <br /> <br />This Certificate of Election To Be Exempt applies only within <br />the scope of business or trade listed on the certificate. <br /> <br />QUESTIONS? (850) 413-1609 <br /> <br />* Carry bottom portion on the job, keep upper portion for your records. <br /> <br />DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-06 <br /> <br />"'~- <br /> <br />.... <br /> <br />. <br />