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dates of coverage or the permit to self-insure. This information will be collected by the licensing agency and <br />retained in their files. <br /> <br />This intbrmation is required by law, and licenses, and permits to operate a business may not be.issued or renewed <br />it' 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 penalty assessed against the applicant by the Commissioner of the Department of Labor <br /> <br />and Industry. <br /> <br />Insurance Company Name: <br />(NOT the insurance agent) <br /> <br />Policy Number: <br /> <br />Dates of Coverage: <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 />I am selfqnsured (include permit to self-insure) <br /> <br />Name: <br /> <br />I have no employees who are covered by the workers' compensation law (these include: Spouse, <br />Parents, Children, and certain farm employees). <br /> <br /> (Last, First, Middle) / <br /> <br />Doing Business As: <br /> <br />(~3usiness Name if different than your name) <br /> <br />Business Address: <br /> <br />City, State, ZIP: ~,ff? }/~ ~fi'~\// <br /> <br /> (~i~[ture) <br /> <br /> <br />