Agenda - Council - 05/09/2000 - Laserfiche WebLink

Home

CERTIFICATION OF COMPLIANCE MINNESOTA WORKERS' COMPENSATION LAW Minnesota Statute, Section 176.182 requires every state and local licensing agency to withhold the issuance or renewal of a license or permit to operate a business or engage in an activity in Minnesota until the applicant presents acceptable evidence of compliance with the workers' compensation insurance coverage requirement of MSS Chapter 176. The information required is: The name of the insurance company, the policy number, and dates of coverage or the permit to self-insure. This information wilt be collected by the licensing agency and retained in their files. This information is required by law, and licenses, and permits to operate a business may not be issued or renewed if it is not provided and/or is falsely reported. Furthermore, if this information is not provided or falsely stated, it may result in a $1,000 penalty assessed against the applicant by the Commissioner of the Department of Labor and Industry. Insurance Company Name: (NOT the insurance agent) Policy Number: Dates of Coverage: (or) I am not required to have workers' compensation liabili~ coverage because: ( ) I have no employees covered by the law. ( ) I am self-insured (include permit to self-insure) ( ) Name: I have no employees who are covered by the workers' compensation law (these include: Spouse, Parents, Children, and certain farm employees). (Last, First, Middle) (Business Name if different thari yofir name) Business Address: City, State, ZB~: (Signature) Date: Phone: I I I I I I I ! I I I I ! I I I I