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PROOF OF WORKERS' COMPENSATION <br />INSURANCE COVERAGE <br />Minnesota Statutes Section 176.182 requires every governmental subdivision entering <br />into a contract for doing any public work to obtain acceptable evidence of compliance with the <br />workers' compensation insurance coverage requirement of Minnesota Statutes Section 176.181, <br />subdivision 2. This information will be furnished, upon request, to the Department of Labor and <br />Industry to check for compliance with 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 <br />not be entered into if it is not provided or is falsely reported. Furthermore, if this information is <br />not provided or is falsely reported, it may result in a penalty assessed against your business by <br />the Commissioner of the Department of Labor and Industry. <br />Provide the information specified above in the spaces provided, or certify the precise <br />reason your business is excluded from compliance with the insurance coverage requirement for <br />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 />^ I have no employees covered by the law. <br />^ Other (specify): <br />I HAVE READ AND UNDERSTAND MY RIGHTS AND OBLIGATIONS WITH REGARD <br />TO PUBLIC CONTRACTS AND WORKERS' COMPENSATION COVERAGE, AND I <br />CERTIFY THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT. <br />(Signature) <br />2010 TREE REMOVALS WITHOUT VEHICULAR ACCESS 4 <br />