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Rug 08 05 07:41a City Heights CERTIFICATION OF COIUIPLIANCE 1VIINl~ESOTA WORi~ERS' COfVIPENSATION LAW Minnesota Statute, 8176.182 requires every state and coca! licensing agency to withhold the issuance or renewal of a license or permit to operate a business or engage in an activity in l~iinnesota until the applicant presents acceptable evidence of compliance with the workers' compensation insurance coverage requirement of I-~S 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 informafiion will be co(iected by the iicensina a eq_ncy and retained in their files This information is required by law, and Licenses and permits to operate a business may not be renewed if it is not provided andlor is falsely reported. Furthermore, if this information is not provided or falsely stated, ft may result in a ~1,DD0 penalty assessed against the applicant by the Commissioner of the Qepartment of Labor and industry. Insurance Company (N~T~ the insurance agent) Policy Number: 1-/ `~~ ~ ~ ~ ~ . Dates of Coverage: / r • ~ J ~ ~ ~`~i• - ~ J d' -~%~ e ~" (or) I am not required to have workers' compensation liability coverage because: () I have no employees ~() I am self insured (include pemut 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° compensation policy will be kept in effect at all limes as required by law. Name: _ ~ ~ ~~l.~r.- ~ ~/,'~ r (last,ftrst,middl.e) Doi Business As: ~ -c ~ C -c ~c .~~- , ~, -c.V ~ ~ i e ~ (business name if different your name) Business Address: (~ ~ - ~ ~ ~~~ -~ ~~ Cits~, State, Zip ~ ~ ~~c ~ ~ S ~ C ~' Phone# ~l? ° ~~/._ ~ ~~ sj Signature: Date: ~~/~,~ 5 :7 •