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PROOF OF WORKER'S COMPENSATION INSURANCE COVERAGE <br /> <br /> Minnesota Statute Section 176.182 requires every state and local licensing agency to withhold the <br />issuance or renewal of a license or permit to operate a business in Minnesota until the applicant presents <br />acceptable evidence of compliance with the worker's compensation insurance coverage requirement of <br />Section 176.181, Subd. 2. The information required is: The name of the insurance company, the policy <br />number, and dates of coverage or the permit to self-insure. This information will be collected by the <br />licensing agency and put in their company file. It will be furnished, upon request, to the Department of <br />Labor and Industry to check for compliance with Minnesota Statute Sec. 176.181, Subd. 2. <br /> <br /> This information is required by law, and licenses and permits to operate a business my not be issued or <br />renewed if it is not provided and/or is falsely reported. Furthermore, if this reformation is not provided <br />and/or reported, it may result in a $1,000 penalty assessed against the applicant by the Commissioner of <br />the Department of Labor and lndustry payable to the Special Compensation Fund. <br /> <br /> Provide the information specified above in the spaces provided, or certify the precise reason your <br />business is excluded from compliance with the insurance coverage requirement for workers' compensation. <br /> <br />Insurance Company Name: <br />(.NOT the insurance agent) <br /> <br />Poll%, Number or Self-Insurance Pem'~it Number:. <br /> <br />Dates of Cov~age: <br /> <br />(or) <br /> <br /> I am nm wqt:ircd to ha;'c v,'c, rkcr~' coverage because: <br />ave no employees covered by the law. <br /> <br /> ( ) O~r <br /> <br />I HAVE READ AND UNDERSTAND MY RIGHTS AND OBLIGATIONS WITH REGARDS TO <br />BUSINESS LICENSES, PERMITS AND WORKER'S COMPENSATION COVERAGE, AND I CERTIFY <br />THAT THE INFORMATION PROV'IDED IS TRUE AND CORRECT. <br /> <br /> <br />