08-26-1987 Council Agenda - Laserfiche WebLink

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PROOF OF WORKERS' COMPENSATION INSURANCE COVERAGE Minnesota Statute Section 176.182 requires every state and local licensing agency to withhold the issuance or renewal of a license or permit to operate a business in Minnesota until the applicant presents acceptable evidence of compliance with the workers' compensation insurance coverage requirement of Section 176.181, Subd. 2. 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 licensing agency and put in their company file. It will be furnished, upon request, to the Department of Labor and Industry to check for compliance with Minnesota Statute Sec. 176.181, Subd. 2. This information is required by law, and licenses and permits to operate a business may not be issued or renewed if it is not provided and /or is falsely reported. Furthermore, if this information is not provided and /or falsely reported, it may result in a $1,000 penalty assessed against the applicant by the Commissioner of the Department lof labor and Industry payable to the Special Compensation Fund. Provide the information specified above in the spaces provided, or certify the precise reason your business is excluded from compliance with the insurance coverage requirement for workers' compensation. Insurance Company Name: (NOT the insurance agent) Policy Number or Self - Insurance Permit Number: Dates of Coverage: (or) I am not required to have workers' compensation liability coverage because: ( ) I have no employees covered by the law. ( ) Other (Specify) I HAVE READ AND UNDERSTAND MY RIGHTS AND OBLIGATIONS WITH REGARDS TO BUSINESS LICENSES, PERMITS AND WORKERS' COMPENSATION COVERAGE, AND I CERTIFY THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT. (SIGNATURE) JA /lc (J) 7/87 Page 126 AUG nEE14) 1D 1987 CITY OF LITTLE CANADA