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iPROOF OF WORKER'S COMPENSATION INSURANCE COVERAGE <br /> <br />~d~ ~ ch~k for ~li~ ~ M~o~ S~ <br /> <br /> ~ ~o~on ~ r~ by law, ~d ~s ~d ~ ~ ~a~ a ~ my not ~ ~su~ or r~ew~ if it ~ not <br />~vi~d ~ ~ f~y r~. P~e, ~ ~ ~o~ ~ not ~vi~ ~or r~ it may re~uh ~ a ~1,~ <br />~nd~ ~a~ ~ ~e ~lic~ by ~e Co~ion~ of ~e ~~t of ~r ~d ~dus~ payable w ~e S~iE <br />Come.on P~d, <br /> <br />~mp~ce wi~ ~e ~ g~ ~v~age ~uff~t for worke~' <br /> <br />].nsu~m~ce iComp~ny N~mc: <br /> <br />Policy N~ ~ber or Sclf-Insurmoe Permit Numbe~. <br />D,,,~ of <br /> <br />(OR) <br /> <br />I am not ~quired t~ have workers' compep~6on liability coverage because: <br />( ~-~ ) have no employees cove. red by the law. <br />( <br /> <br />I HAVE READ ~ UNDERSTAND lvI'Y RIGHTS AND OBLIGATIONS ~ REGARDS TO BUSINESS <br />LICENSES, PE .RMITS AND WORKER'S COM~PENSAT/ON COVERAOE, AND I CERTIFY THAT TH~ <br />INFORMATION I~ROVIDED IS TRUE AND CORRECT. <br /> <br /> <br />