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<br />CERTIFICATION OF COMPLIANCE <br />MINNESOTA WORKERS' COMPENSATION LAW <br /> <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 bv the licensing agency and <br />retained in their files. <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, 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 /> <br />Insurance Company Name: <br />iliOT the insurance agent) <br /> <br />_A ~~\-o - O\.0f\e..-~s:" -\ -,\(\~ <br /> <br />0<65SL.\- ~~s- <br />\'{\~ ~I ~C)Ol ~ <br />(or) <br /> <br />~~. ~o~ <br />j <br /> <br />Policy Number: <br /> <br />Dates of Coverage: <br /> <br />I am not required to have workers' compensation liability coverage because: <br /> <br />( <br /> <br />I have no employees covered by the law. <br /> <br />( <br /> <br />) <br /> <br />] am self-insured (include permit to self-insure) <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 />(Last, First, Middle) <br /> <br />Doing Business As: <br /> <br />(Business Name if different than your name) <br /> <br />Business Address: <br /> <br />City, State, ZIP: <br /> <br />Phone: ( <br /> <br />) <br /> <br />Date: <br /> <br />(Signature) <br /> <br />-201- <br /> <br />