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CERTI??ICATION Oil' COMPI.,.IAN CE <br />.,MINNESOTA WORKERS; COMPENSATION <br /> <br />Minnesota Statute, Section 176.182 requires ever.'i state and local licensing agency to withhold she issuance or <br />renewal ora license or permit to operate a business or engage m an act~vtty in Minnesota until the appiicam <br />presents acceptable evidence of compliance with the workers' compensation tnsurance coverage requirement of <br />MSS Chapter 176. The inibrmation required is: The name of the insurance company, the policy number, and <br />dates of coverage or the permit to self-insure. This infbrrnation will be collected bv the hcensina aaencv and <br />retained m their <br /> <br />This information is required by law, and licenses, and permits to operate a business may not be issued or renewed <br />if it is not provided and/or is falsely reported. Furthermore, it' this infbrmation is not provided or fitl~ely stated, it <br />may result its a $1,000 penalty assessed against the appimant by the Commissioner of the Depm'tment of Labor <br />artd h-~dt:s~ry <br /> <br />Insurance C:ompany Name: <br />(N()T the insurance; agent) <br /> <br />Policy <br /> <br />Dates ', ' ' <br /> <br />i am not reqmred to have workers compensation lia0iiiry coverage because: <br /> <br />( <br /> <br />1 have no empioyees covered by rite law. <br /> <br />.) <br /> <br />I am seif-msured I. tnciude permit to seif-msure) <br /> <br />Parents, Children, and certain farm employees). <br /> ,.La~t, :~'i:'st, ''" ' <br /> <br />I have no employees who are covered by the workers' compensatmn law (these znclude: Spouse, <br /> <br />iBusmess Name if different man your name) <br /> <br /> <br />