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• <br /> PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE <br /> STATE OF FLORIDA 1 MPORTANT <br /> DEPARTMENT OF FINANCIAL SERVICES + ' ? F <br /> DIVISION OF WORKERS' COMPENSATION ri O Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who <br /> CONSTRUCTION INDUSTRY K. ;r elects exemption tion from this chapter ter b y filing <br /> certificate of election <br /> CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA .g g <br /> WORKERS' COMPENSATION LAW L under this section may not recover benefits or compensation under this <br /> D chapter. <br /> EFFECTIVE: 07/16/2009 EXPIRATION DATE: 07/16/2011 <br /> Pursuant to Chapter 440.05(12), F.S., Certificates of election to be <br /> PERSON: KENNETH L PRICKETT II H exempt.. apply only within the scope of the business or trade listed on <br /> FEIN: 205321218 R the notice of election to be exempt. <br /> BUSINESS NAME AND ADDRESS: E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt <br /> SPECIAL OPS BUILDERS MC e exem p <br /> and certificates of election to be exempt shall be subject to revocation <br /> 37731 KOSSIK RD if, at any time after the filing of the notice or the issuance of the <br /> ZEPHYRHILLS, FL 33541 certificate, the person named on the notice or certificate no longer meets <br /> the requirements of this section for issuance of a certificate. The <br /> department shall revoke a certificate at any time for failure of the <br /> SCOPE OF BUSINESS OR TRADE: person named on the certificate to meet the requirements of this <br /> 1- CERTIFIED BUILDING CONTRACTOR section. <br /> QUESTIONS? (850) 413 -1609 <br /> CUT HERE <br /> * Carry bottom portion on the job, keep upper portion for your records. <br /> DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 <br /> • <br />