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CERTIFICATION OF COMPLIANCE <br /> MINNESOTA WORKERS' COMPENSATION LAW <br /> Minnesota Statute, Section 176.182 requires every state and local licensing agency to withhold <br /> the issuance or renewal of a license or permit to operate a business or engage in an activity in <br /> Minnesota until the applicant presents acceptable evidence of compliance with the workers' <br /> compensation insurance coverage requirement of Chapter 176. The information required is:the <br /> name of the insurance company,the policy number, and dates of coverage or the permit to self <br /> insure. This information will be collected by the licensing agent and retained in their files. <br /> This information is required by law, and licensing and permit to operate a business may not be <br /> issued or renewed if it is not provided and/or falsely reported. Furthermore, if this information is <br /> not provided or falsely stated, it may result in a$2,000 penalty assessed against the applicant by <br /> the Commissioner of the Department of Labor and Industry. <br /> Insurance Company Name: Mo/?SF 1)C Cfro C Y YLC <br /> (NOT the insurance agent) <br /> Policy Number: <br /> Date of Coverage: /0/l 9 To (Cl/r 9/ri o <br /> • <br /> (OR) <br /> I am n t required to have workers' compensation liability coverage because: <br /> ((Y I have no employees <br /> ( ) I am self insured (iinclude permit to self-insure) <br /> ( ) I have no employees who are covered by the workers' compensation law(these include: <br /> Spouse,Parents, Children and certain farm employees) <br /> I certify that the information provided above is accurate and complete and the a valid workers' <br /> compensation policy will be kept in effect at all times as required by law. <br /> • <br /> Print Full Name: IVa PA a. Lor,'`�4. <br /> Doing Btusinfms As: l cp li c L n 3-1-n,r P. <br /> Business Adder: 2 5 5 3 9Zw est- trf U s / O <br /> City, State, Zip: 04t (A V I -co/ r,u 24411) 55// <br /> (12(4- 1 —gci4( Z. <br /> Phone: —' <br /> Signature: <br /> N:IUSERSICARLSSACKUPILYNNETTEILICENSES1wORKERSC.FRM <br />