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_�_ <br /> 12 -29 -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: 12/29/2010 EXPIRATION DATE: 12/28/2012 <br /> PERSON: NAULT LEON R <br /> FEIN: 352390015 <br /> BUSINESS NAME AND ADDRESS: <br /> TRIPLE CROWN ROOFING INC <br /> 37625 STATE ROAD 54 <br /> ZEPHYRHILLS FL 33542 <br /> SCOPES OF BUSINESS OR TRADE: <br /> 1- ROOFING <br /> IMPORTANT: Parseaot to Chapter 440 . 05(14), F.S., se officer of a corporation who elects exemption from this chapter by filing a certificate of election soder this <br /> section may oat recover benefits or campeusatiu ender this chapter. Perseast to Chapter 440.05(12), F.S., Certificates of election to be exempt... apply only within the <br /> scope of the business er trade listed on the notice of election to be exempt. Portent to Chapter 440.05(13), F.S., Notices of election to be exempt end certificates of <br /> election to be exempt shall be subject to revocation it, at say time after He filing o1 the entice or the ivaaace of the certificate, the person Named ea the notice or <br /> certificate no lager meets the requirements of this uctios for issuance of a certificate. The department shall revoke a certificate at any time for failure of Me perm' <br /> earned on One certificate to meet the requirements of this section. <br /> 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 <br /> DEPARTMENT OF FINANCIAL SERVICES ; _ : F IMPORTANT <br /> DIVISION OF WORKERS' COMPENSATION <br /> CONSTRUCTION INDUSTRY , f `" %r Pursuant to Chapter 440 05(14), F.S., an officer of a corporation who <br /> CERTFICATE OF ELECTION _., elects exemption from this chapter by filing a certificate of election <br /> TON TO EXEMPT FROM FLORIDA 0� L under this section may not recover benefits or compensation under this <br /> D chapter. <br /> EFFECTIVE 12/29/2010 EXPIRATION DATE 12/28/2012 Pursuant to Comer 440.05112), F.S., Certificates of election to be <br /> PERSON LEON R NAULT H exempt_ apply only within the scope of the business or trade listed on <br /> FE)N 352390015 R Y the notice of election to be exempt <br /> BUSINESS NAME AND ADDRESS E Pursuant to Chapter 440.05(13), F.S., Notices o <br /> Notif election to be ex <br /> TRIPLE CROWN ROOFING INC exempt <br /> and certificates of election to be exempt shall be subject to revocation <br /> 37625 STATE ROAD 54 if, at any time after the filing of the notice or the issuance of the <br /> ZEPHYRHILLS. FL 33542 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- ROOFING 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 />