Agenda - Council - 07/27/1999 - Laserfiche WebLink

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CERTIFICATION OF COMPLIANCE MINNESOTA WORKERS' COMPENSATION LAW Minnesota Statue, 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 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 will 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 $2,000 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: to. (or) I am not required to have workers' compensation liability coverage because: ( ) I have no employees ( ) I am Self-insured (include permit to self-insure) ( ) I have no employees who are covered by the workers' compensation law (these include: Spouse, Parents, Children and certain farm employees) I certify that the information provided above is accurate and complete and that a valid workers' compensation policy will be kept in effect at all times as required by law. Name: (Last, First, Middle) Doing Business As: Business Address: City, State, Zip: Signature: (Business name if different than your name) Phone:( ) Date: I I ! I I