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CHIEF FINANCIAL OFFICER
STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
**CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW**
CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law.
EFFECTIVE DATE: 6/19/2024 EXPIRATION DATE: 6/19/2026
PERSON: ANDREA ADAMS EMAIL: ALEHMAN@STATEWIDEIMPACTWINDOWS.0
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FEIN: 474719606
BUSINESS NAME AND ADDRESS:
STATEWIDE WINDOWS & DOORS, INC
3725 INVESTMENT LN,
WEST PALM BEACH, FL 33404
This certificate of election to be exempt is NOT a license issued by the Department of Business and Professional
Regulation.To determine if the certificate holder is required to have a license to perform work or to verify the
license of the certificate holder, go to www.myfloridalicense.com.
IMPORTANT:Pursuant to subsection 440.05(13),F.S.,an officer of a corporation who elects exemption from this chapter by filing a certificate
of election under this section may not recover benefits or compensation under this chapter.Pursuant to subsection 440.05(11), F.S.,
Certificates of election to be exempt issued under subsection(3)apply only to the corporate officer named on the notice of election to be
exempt.Pursuant to subsection 440.05(12), F.S.,notices of election to be exempt and certificates of election to be exempt shall be subject to
revocation if,at any time after the filing of the notice or the issuance of the certificate,the person named on the notice or certificate no longer
meets the requirements of this section for issuance of a certificate.The department shall revoke a certificate at any time for failure of the
person named on the certificate to meet the requirements of this section.
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT E01948989 QUESTIONS?(850)413-1609
Rule 69L-6.012, F.A.C. REVISED 01/2023
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