CANCELLATION NOTICE (009)
FLOI_IDA CONSTRUCTION, COMMERCE anc(-,mUSTRY
SELF INSURERS FUND
P.O. Box 1616
Sarasota, Florida 33578-1616
,___r
11/21'
DATE
CLEARWA1"ER
TV' A TfORN:::V.
4748
E J:t;:,i;.;',fl,.' i~'i5 1 B
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that:
Ll w;~~~~~':i~~~~ON
3645"""STH aWE. ,'IIORl"H
ST. ~~TERS8~R_ FL
DE
337 1 "
err
the provisions ohhe Florida Worker's Compensation Act,
Jayment of compensation by insuring their risk with the
STRUCTION, COMMERCE ANO.;fNtlUSTRYSELF INSURERS FUND.
IS SU3JECT TO CAN~~t:~;~~b~WITH 30 OAYSNOTICE TO IIIfSlJR
F.C.C.!. Claims Service ....,......,.....,....,.,.........,'.
P. O. Box 25248
Sarasota, FL 34277-2248
12 - 0 I
R~e~~y '~,:t~~,~ /__
J;;) ..f.,<A..-<:-f '-1/ v ;-''-''' '
'''' ()<:
B EH: 0071 6 - 01
E: l'OI/B5
fE: 12'31'36
year, still with the Fund, will receive refunds of up to 59% of premium, based on GOOD SAFETY EXPEl