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~~ CERTIFICATION OF COMPLIANCE MINNESOTA WORKERS' COMPENSATION LAW Minnesota Statute, §176.182 requires every state and local licensing agency to withhold the issuance or renewal of a license or permit to operate a business or engage in an activity in Minnesota until the applicant presents acceptable evidence of compliance with the workers' compensation insurance coverage requirement of MSS Chapter 176. The information required is: the name of the insurance company, the policy number, and dates of coverage or the permit to self insure. This information will be collected by the ficensina aaencv and retained in their filers • This information is required by law, and licenses and permits to operate a business may not be renewed if it is not provided and/or is falsely reported. Furthermore, if this information is not provided or falsely stated, it may result in a X1,000 penalty assessed against the applicant by the Commissioner of the Department of Labor and industry. . Tnc~irance Company• Name: (NOT) the insurance agent) • . Policy Number: Dates of Coverage: to (or) • • I am not required to have workers' compensation liability coverage because: • • O I have no employees ~() I am self-insured (include permit to self-insure) ~} I have no employees who are covered 'by the workers' compensation law (these include: Spouse,Parents,Children and certain farm employees) I certify that the information provided above is accurate and complete and that a valid workers' compensatio,. olicy will be kept in effect. at all times as required by law. Name: ('~ i~ .~e /~a ~ Y.,,~ ,, ~ ~~ • st,first,middle) Doing Business As: (business name if different than your name) Business Address: _ ~~ ~ G ~ ~f ~ 7 City,State,Zip: `' w ~ ~ w ~(~ • / ' - ~•-:°~ ~ ~I ~ Phone#~ ~ v 3 ~ ~ .2 ~ ~ j 5 ~Qnature: >~=~~~ U C `/ Date: ~ °- - Q ~ 7