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06 -02 -2010 <br /> ALEX SINK STATE OF FLORIDA <br /> CHIEF FINANCIAL OFFICER 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 /> This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. <br /> EFFECTIVE DATE: 06/02/2010 EXPIRATION DATE:. 06/01/ 2012 <br /> PERSON: LANE JOHN <br /> FEIN: 200405836 <br /> BUSINESS NAME AND ADDRESS: <br /> DISCOUNT SCREEN SERVICE INC <br /> 736 WEST FORT DADE AVENUE <br /> BROOKSVILLE ' FL 34601 <br /> SCOPES OF BUSINESS OR TRADE: <br /> 1- ALUMINUM CONTRACTOR <br /> IMPORTANT: Pursuant to Chapter 440. 054141, F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this <br /> section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(121, F.S., Certificates of election to be exempt... apply only within the <br /> scope of the business or trade listed on the notice of election to be exempt. Persoaat to Chapter 440.05413 ), F.S., Notices of election to be exempt and certificates of <br /> election to be exempt shall be subject to revocation If, at any time alter the filing of the notice or the issuance of the certificate, the person named ou the notice or <br /> certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate et any time for failure of the person <br /> named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413-1609 <br /> DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 <br /> PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE <br /> STATE OF FLORIDA IMPORTANT <br /> DEPARTMENT OF FINANCIAL SERVICES .t!' 'Y <br /> DIVISION OF WORKERS' COMPENSATION + F to Chapter 440.05(14), F.S., an officer of a corporation who <br /> CONSTRUCTION INDUSTRY O elects exemption from this chapter by filing a certificate of election <br /> CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA p L under this section may not recover benefits or compensation under this <br /> WORKERS' COMPENSATION LAW D chapter. <br /> EFFECTIVE: 06 /02/2010 EXPIRATION DATE: 06 Pursuant to Chapter 440.05112), F.S., Certificates of election to be <br /> PERSON: JOHN LANE H exempt... apply only within the scope of the business or trade listed on <br /> FEIN: 200405836 E 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 /> DISCOUNT SCREEN SERVICE INC and certificates of election to be exempt shall be subject to revocation <br /> 736 WEST FORT DADE AVENUE if, at any time after the filing of the notice or the issuance of the <br /> BROOKSVILLE, FL 34601 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- ALUMINUM 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 />