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PROOF OF WORKERS' COMPENSATION <br />INSURANCE COVERAGE <br />Minnesota Statutes Section 176.182 requires every governmental subdivision entering into a contract for <br />doing any public work to obtain acceptable evidence of compliance with the workers' compensation <br />insurance coverage requirement of Minnesota Statutes Section 176.181, subdivision 2. This information <br />will be furnished, upon request, to the Department of Labor and Industry to check for compliance with <br />Minnesota Statutes Section 176.181, subdivision 2. <br />This information is required by law, and a contract for the doing of any public work may not be entered into <br />if it is not provided or is falsely reported. Furthermore, if this information is not provided or is falsely <br />reported, it may result in a penalty assessed against your business by the Commissioner of the Deparirnent of <br />Labor and Industry. <br />Provide the information specified above in the spaces provided, or certify the precise reason your business is <br />excluded from compliance with the insurance coverage requirement for workers' compensation. <br />INSURANCE COMPANY NAME: <br />(NOT the insurance agent) <br />POLICY NO.OR SELF-INSURANCE PERMIT NO.: <br />DATES OF COVERAGE: <br />-OR- <br />I am not required to have workers' compensation liability coverage because: <br />o I have no employees covered by the law. <br />^ Other (spec~): <br />I HAVE READ AND UNDERSTAND MY RIGHTS AND OBLIGATIONS WITH REGARD TO <br />PUBLIC CONTRACTS AND WORKERS' COMPENSATION COVERAGE, AND I CERTIFY THAT <br />THE INFORMATION PROVIDED IS TRUE AND CORRECT. <br />(Signature) <br />URBAN FORESTRY SERVICES AGREEMENT <br />CITY OF MOUNDS VIEW <br />