Laserfiche WebLink
Dct- 18 05 03:32p City of Falcon Heights 6516448675 p.5 <br />CERTIFlGATiOhI pF COMPLI.4~~F. <br />. MlNI~eS~TA VI/~Rf~~RS' ~~OMFE~~~~,Tt(JIV LAIN <br />Minnesota S#atUt~, '17~. <br />~ 9$~ requires awry star arFd iota! ficer~sina a~°,`~c}' to <br />w~thhofci tfze tasuance ar renewal a# a (icanse or permit fio oi3a, ate ~vb;~sinesr <br />e~agage in an aLtivlty in IVlinnesofia ur~tli the appli;,ant prese,n~ acce to a ev,~en,e of <br />camp(iance with ttte workers' compensation )rtsuran l,' bl <br />Chapter 1?6. Ths information required ?s: the name ~f fh~ insurarced ~m amf ~^~ <br />pal)cy number, and dates of coverage ar the permit to se ~• ~ q nt a, ~„~.~ <br />wil+ be Collected b ~ n li tnsure, ~ri,l5 )rlfJnTiB'Ciot~ <br />tf7., lican5in a BnCV ~~~ retainarf fr, :t,..:. r.,__ <br />----.` <br />This )nfarmatlon is .''eawired by law,- and licenses and hermits to operate a f~us?nes <br />nzay not be rena5~red if it is oat provided a,ndior is fa?set ~ re s <br />thts +nfarrnat~on js oat provided or salssly simted. it mau resuf~)r~ea ~~ ~Cerrrrore, i` <br />assessed against the applicant by tha Carnm)ssioner of the Department of L bofir an4 <br />Industry, <br />iesuranee Compan37~ Name: --~ 3 <br />I I.NOT} the S~nsurarce age~~ .. <br />Policy ?~umbe-,:,~_ ~ `~ ! ~ ~ ~S' ~/ <br />Dates of Covera~e;~~z~~ ~ ~~ <br />t~ <br />for} .. <br />I am not reauire~ tp nave wor~exs' compensation liability covprape laecause: <br />,) I have no employees <br />• ~{) i am selr"-ir_s:ued {mclude Ormit to se ~=' ~ <br />P L ans~e) <br />C) ~ have no anplaye; s who are covere <br />Snause,l~arerns,~:aildren and certain farm emplovees~ess compensation Iaw ftlzese include: <br />I certify that file iniormzz~ion provided aha~~e s~ a:curate a~ complete ansi fhat a valid. <br />workers° compex~adon polic% will k+e kep~ in W~f'ect at all 'rm:s aF required by law, <br />Tdr3me: - ~~-~ '~~ ~'~- <br />(l~tet, fixst, middle ) <br />Doing Businesa As; f/ ~<'vl ~ y~ <br />C~ct r ~~Q <br />C~ <br />{bnsin°ss name. if different than your nau~°) <br />Buau~.ss 4ciare5s; t~ ~~~' ;~~~ ~! ~ . ~ _ <br />r~ <br />s <br />Czi~r, State,'ip: ~ ,~'~ tP i rll a :, ~~-~. pho~e,~`_~ f ~ ~~~ „ c~/' <br />Siv~al.~.re:~ ~ ,~~ / ~~ <br />i?ate; ^~ <br /> <br />