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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 renewal of <br />a license or permit to operate a business or engage in an activity in Minnesota until the applicant presents acceptable <br />evidence of compliance with the workers' compensation insurance coverage requirement of MSS Chapter 176. The <br />information required is: The name of the insurance company, the policy number, and dates of coverage or the permit to <br />self -insure. This information will be collected by the licensing aaencv and retained in their files. <br />This info,. cation is required by law, and licenses, and permits to operate a business may not be issued or renewed if it is <br />not provided and/or is falsely reported. Furthermore, if this information is not provided or falsely stated, it may result in a <br />$1,000 penalty assessed against the applicant by the Commissioner of the Department of Labor and Industry. <br />Insurance Company Name: GLOr- ijvt... k L U& t. I ®C--\ <br />(NOT the insurance agent) <br />Policy Number: & L . (� <br />//, ,ot/ — 0 c+ l 1 <br />(or) <br />I am not required to have workers' compensation liability coverage because: <br />Dates of Coverage: <br />( i'� ) I have no employees covered by the law. <br />( <br />( <br />Name: <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 />wVe914. Ctl A—tA., <br />(Last, First, M. 1e) <br />Doing Business As: b1 G S'` cai <br />Business Address: Cs <br />City, State, ZIP: <br />(Business Name if different than your name) <br />0 <br />NV\v1V i/ `1 ]qho : (6.51) go- f 3?( <br />I DOLL, <br />Our Mission: To work together to responsibly grow our community, and to provide quality, cost-effective, and efficient government services <br />