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�.�{E 3� <br /> !�. .L I 09-03-2010 <br /> \��;��s/ <br /> ALEX SINK STATE OF FLORIDA <br /> CHIEFFINANCIALOFFICER 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: 10/09/2010 EXPIRATION DATE: 10/08/2012 <br /> PERSON: DUBOIS STEVEN M <br /> FEIN: 204883108 <br /> BUSINESS NAME AND ADDRESS: <br /> STEVEN M DUBOIS ROOFING OF PASCO INC <br /> 15348 GREENGLEN LANE <br /> SPRING HILL FL 34610 <br /> SCOPES OF BUSINESS OR TRADE: <br /> 1- ROOFING <br /> IMPDflTANT Pursuant to Chapter 440 051141, F.S., an of(icer of a corpontion who elects exemption from this chepter by filing a certificate of election under this <br /> sectian may not recorer 6eneFits or compensation under this chapter Pursuent to Chapter 440.05112), F.S., CertiFic�[es of election to be exempt.. spply only within the <br /> scope oF the business or trade listed on the notice oF elec�ion [o be exempt. Pursuant to Ch�pter 440.051131, F.S., Notices of election to be exempt end certifica[es oF <br /> election to be exempt shall be Subject to revocation if, st eny time afte� [he filing of the notice ar the issuance of [he certificale, tAe person named on the notice or <br /> certilicete no longer meets the requirements al Ihis section for issuance of a certificate. The department shall revoke a certificate at any time for failure af the person <br /> nemed on the certificate to meet the requirements of this section. <br /> QUESTIONS? (850) 413-1609 <br /> WC-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 1 MPORTANT <br /> DMSION OF WORKERS'COMPENSATION Pursuant to Chapter 440.05(14�, F.S., an officer of a corporation who <br /> CONSTRUCTION INDUSTRY � elects exemption from this chapter by filing a certificate of election <br /> CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA L under this section may not recover benefits or compensation under this <br /> WORKERS'COMPENSATION LAW D chepter. <br /> EFFECTIVE: 10/09/2010 EXPIRATION DATE: 10/08/2012 pursuant to Chapter 440.05112►, F.S., Certificates of election to be <br /> PERSON: STEVEN M DUBOIS H exempt... apply only within the scope of the business or trade listed on <br /> FEIN: 204883108 R the notice of election to be exempt. <br /> BUSINESS NAME AND ADDRESS: E Pursuant to Chapter 440.05113), F.S., Notices of electian to be exem t <br /> STEVEN M DUBOIS ROOFING OF PASCO INC p <br /> and certificates of election to be exempt shall be subject to revocation ' <br /> 75348 GREENGLEN LANE if, at any time after the filing of the notice or the issuance of the I <br /> SVRING HILL, Fl sasio 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 tailure of the <br /> SCOPE OF BUSINESS OR TRADE: person named on the certificate ta meet the requirements of this i <br /> 1- ROOFING section. <br /> QUESTIONS? (850) 413-1609 <br /> I <br /> CUT HERE ; <br /> � Carry bottom portion on the job, keep upper portion for your records. <br /> WC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09-06 <br />