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PROOF OF WORKERS' COMPENSATION INSURANCE COVERAGE <br /> <br /> Minnesota Statute Section 176.182 requires every state and local licensing <br />agency to withhold the issuance or renewal of a license or permit to operate a <br />business in Minnesota until the applicant presents acceptable evidence of <br />compliance with the workers' compensation insurance coverage requirement of Section <br />176o181, Subd. 2. The information required is: The name of the insurance company, <br />the policy number, and dates of coverage or the permit to self-insure. This <br />information will be collected by the licensing agency and put in their company <br />file. It will be furnished, upon request, to the Department of Labor and Industry <br />to check for compliance with Minnesota Statute Sec. 176.181, Subd. 2. <br /> This information is required by law, and licenses and permits to operate a <br />business may not be issued or renewed if it is not provided and/or is falsely <br />reported. Furthermore, if this information is not provided and/or falsely <br />reported, it may result in a S1,DO0 penalty assessed against the applicant by the <br />Co~issioner of the Department )of labor and Industry payable to the Special <br />Compensation Fund. <br />x Provide the information specified above in the spaces provided, or certify the <br />precise reason your business is excluded from compliance with the insurance <br />coverage requirement for workers' compensation. <br /> <br />Insurance Company Name: . ~ ~,~,~x~c.. <br />(NOT the insurance agent}- ' <br /> <br />Policy Number or Self-Insurance Permit Number: <br /> <br />Dates of Coverage: <br /> <br />(or) <br /> <br />I am not required to have workers' compensation liability coverage because: <br /> <br />( ) I have no employees covered by the ~aw. <br /> <br />( ) Other (Specify} <br /> <br />I HAVE READ AND UNDERSTAND HY RIGHTS AND OBLIGATIONS WiTH <br />LICENSES, PERMITS AND WORKERS' COHPENSAT!ON COVERAGE, <br />iNFORMATiON PROVIDED IS TRUE AND CORRECT. <br /> <br />REGARDS TO BUSINESS <br />AND I CERTIFY THAT THE <br /> <br />aA/lc (J) 7/87 <br /> <br /> <br />