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CERTIFICATION OF ~OMPLIANCE <br />MINNESOTA WORKERS' COMPENSATION LAW <br /> <br />Minnesota Stature, Section 176.182 requires eveu state and local licensing agency to withhold the issuance or <br />~'enewal of a }icense or permit to operate a business or engage in an activiq, in Minnesota until the applicant <br />presents acceptable evidence of comphance with the workers' compensation insurance coverage requirement of <br />MSS Chapter 176. The information reqmred is: The name of the insurance company, the policy number, and <br />dates of coverage or the permit to self-insure. This information will be collected bv the licensin.~ a~encv and <br />retained in then- files. <br /> <br />This information is required by law, and licenses, and perrni.ts to operate a business may not be issued or renewed <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 m a $1,000 penalty assessed against the applicant by the Con-maissioner of the Department of Labor <br />and Industry. <br /> <br />Insurance Compalny Nan]e: <br />('NOT the insurance agent) <br /> <br />Policy Number: <br /> <br />Dates of Coverage: <br /> (o,') <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 ann self-insured (include pemait to self-insure) <br /> <br />( ) <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 />Name: <br /> <br />Doing Business As: <br /> <br />(Last, First, Middle) <br /> <br />(Business Name if different than your name) <br /> <br />Business Address: <br /> <br />City, State, ZP: <br /> <br />Phone: <br /> <br />(S i gn, arure) <br /> <br />-Il- <br /> <br /> <br />