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JDN-14-19D~ 08:2~ CITY <br /> <br /> CERTIFICATION OF COM'PLIANCE <br />MIN2xFESOTA WOiR. KERS' COMPENSATION LAW <br /> <br />Mir. neSota Statute, Section 17t5.182 requires every state and loom licensing agency to w/thhold the issuance or <br />renewal of a license or permit to operate a business or engage in an acti','ity in Minnesota until the applicant <br />presents acceptable evidence of compliance with the workers' compensation insurance coverage requirement of <br />MSS Chapter 176. 'l'lx~ information required is: The name of the insurance company, the policy number, and <br />dates of coverage or the permit to self-insure..This inf0rmatioq 'trill be collec~d_by_th, licensing agency and. <br />retairted in their files. <br /> <br />This information is required by law, and l(censes, and permits to operate a business may not be issued or rencwved <br />if it is not provided and/or is falsely reported. Furthermore, if this information is not provided or falsely stated, it <br />may result in a $1,000 penalt-7 assessed against the applicant by the Commissioner of the Department of Labor <br />and Industry. <br /> <br /> ' '(or) <br />I am not required to have workers' compensation liability coverage because: <br /> <br />( ) I have no employees covered by the law. <br /> <br />( ) <br /> <br />I am self-insured (include permit to self-ir~ure) <br /> <br />( ) <br /> <br />Name: <br /> <br />Doing Business As: . <br /> <br />Business Address: <br /> <br />City, State, ZiP: <br /> <br />I have no employees wl",o are covered by tl-.e workers' comp~sation law (these include: Spouse, <br />Parents, Chi!dre~, and certain farm employees). <br /> <br /> (Last, First, Middle) / <br /> <br /> LBusin~ss Name if different than you/name) <br /> <br />.. Date: <br /> <br />(Signature) <br /> <br />10 <br /> <br /> I <br /> I <br /> <br /> I <br /> I <br /> I <br /> I <br /> I <br /> ! <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br /> <br /> <br />