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CERTIFICATION OF COMPLIANCE <br />MINNESOTA WORKERS' COMPENSATION LAW <br />Minnesota Statute, §176.182 requires every state and focal licensing agency to <br />withhold the issuance or renewal of a license or permit to operate a business or <br />engage in an activity in Minnesota until the applicant presents acceptable evidence of <br />compliance with the workers' compensation insurance coverage requirement of MSS <br />Chapter 176. The information required is: the name of the insurance company, the <br />policy number, and dates of coverage or the permit to self insure. This information <br />will be collected by the iicensina agency and retained in their fifes <br />This information is required by law, and licenses and permits to operate a business <br />may not be renewed if it is not provided and/or is falsely reported. Furthermore, if <br />this information is not provided or falsely staffed, it may result in a $1,000 penalty <br />assessed against the applicant by the Commissioner of the Qepartment of Labor and <br />industry. <br />Insurance Company' Name: ~ ~ ~,~ <br />(NOS the insurance agent) <br />Policy Number: ~ ~ ~ ~ " G G U ~ c~ 12 9 ~'~ <br />Dates of Coverage: ~~~ ~1' ~ b ~ to ~ (~- ~ ~~; ~~ <br />(or) <br />I am not required to have workers' .compensation liability coverage because: <br />O I have no employees • <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: <br />Spouse,Parents,Chfldren and certain farm employees) <br />I certify that the information provided above is accurate and complete and that a valid <br />workers' compensation policy will be kept in effect at all times as required by law. <br />Name: <br />(last,first,middle) <br />Doing Business As: <br />(business name if different than your name) <br />Business Address: <br />City, State,Zip : Phone# <br />S ~anature: Date: ~ ` ~ ~ Sf • <br />