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STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICIES
DIVISION OF WORKERS'COMPENSATION
* * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW
CONSTRUCTION INDUSTRY EXEMPTION
TNs certifies ftt the Individual listed below has elected to be "emptiram Florida Workers! Compensation law.
EFFECTPIE DATE: 71901115 EXPIRATION DATE: 718r2017
PERSON: BASSETT GREGORY R
FEIN: 461974689
BUSINESS NAMEAND ADDRESS:
WELLWORTH PLUMBING LLC
1016 ANTILLES AVE.
By
St. Lucie
FORT PIERCE FL 34982
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SCOPES OF BUSINESS OR TRADE:
LICENSED PLUMBING
CONTRACTOR
I
DFS-F24MO,M �TIFI(AM OF�K)N TO BE S(EMPT REVIEW M13
GU�IONS? (850)413-16RD
https:llapps8.fldfs.comlcrreportviewerlreportViewer.aspx?data7—kdvpginc9D7Q3gH6TER6e... 6/4/2015