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CERTIFICATION OF COMPLIANCE <br /> MINNESOTA WORKERS' COMPENSATION LAW <br /> Minnesota Statute, Section 176.182 requires every state and local licensing agency to withhold the issuance or <br /> renewal of a license or permit to operate a business or engage in an activity in Minnesota until the applicant <br /> presents acceptable evidence of compliance with the workers' compensation insurance coverage requirement of <br /> MSS Chapter 176. The information required 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 by the licensing agency and <br /> retained in their files. <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, 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 /> and Industry. <br /> Insurance Company Name: <br /> (NOT the insurance agent) <br /> Policy Number: <br /> Dates of Coverage: <br /> (or) <br /> I am not required to have workers' compensation liability coverage because: <br /> ( ) I have no employees covered by the law. <br /> ( ) I am self-insured(include permit to self-insure) <br /> ( ) I have no employees who are covered by the workers' compensation law(these include: Spouse, <br /> Parents, Children, and certain farm employees). <br /> Name: <br /> (Last,First,Middle) <br /> Doing Business As: <br /> (Business Name if different than your name) <br /> Business Address: <br /> City, State,ZIP: Phone: ( ) <br /> Date: <br /> (Signature) <br />