My WebLink
|
Help
|
About
|
Sign Out
Home
Browse
Search
12-19-1995 CC
MoundsView
>
City Council
>
City Council
>
Packets
>
1990-1999
>
1995
>
12-19-1995 CC
Metadata
Thumbnails
Annotations
Entry Properties
Last modified
7/2/2018 10:40:01 AM
Creation date
7/2/2018 10:39:50 AM
Metadata
Fields
Template:
MV City Council
City Council Document Type
City Council Packets
Date
12/19/1995
There are no annotations on this page.
Document management portal powered by Laserfiche WebLink 9 © 1998-2015
Laserfiche.
All rights reserved.
/
97
PDF
Print
Pages to print
Enter page numbers and/or page ranges separated by commas. For example, 1,3,5-12.
After downloading, print the document using a PDF reader (e.g. Adobe Reader).
View images
View plain text
PROOF OF WORKERS' COMPENSATION INSURANCE COVERAGE <br /> Minnesota Statute Section 176. 182 requires every state and local <br /> licensing agency to withhold the issuance or renewal of a license or <br /> permit to operate a business in Minnesota until the applicant presents <br /> acceptable evidence of compliance with the workers ' compensation <br /> insurance coverage requirement of Section 176 . 181, Subd. 2 . The <br /> information required is: The name of the insurance company, the policy <br /> number, and dates of coverage or the permit to self-insure. This <br /> information will be collected by the licensing agency and put in their <br /> company file. It will be furnished, upon request, to the Department of <br /> Labor and Industry to check for compliance with Minnesota Statute Sec . <br /> 17 6-15-1,—ubei.-2-. <br /> This information is required by law, and licenses and permit to <br /> operate a business may not be issued or renewed if it is not provided <br /> and/or is falsely reported. Furthermore, if this information is not <br /> provided and/or falsely reported, it may result in a $1,000 penalty <br /> assessed against the applicant by the Commissioner of the Department of <br /> Labor and Industry payable to the Special Compensation Fund. <br /> Provide the information specified above in the spaces provided, or <br /> certify the precise reason your business is excluded form compliance <br /> with the insurance coverage requirement for workers ' compensation. <br /> Insurance Company Name: /< )4- /( NS d" 4) ''-'4e4/0/' LA/C_ <br /> (NOT the insurance agent) <br /> Policy Number of Self-Insurance Permit Number: SS R 437 77 <br /> Dates of Coverage: J*[.fir- / /yys' J 04Y / / Y <br /> (or) <br /> I am not required to have workers ' compensation liability coverage <br /> because: <br /> M I have no employees covered by the law. <br /> ( ) Other (Specify) <br /> I HAVE READ AND UNDERSTAND MY RIGHTS AND OBLIGATIONS WITH REGARDS TO <br /> BUSINESS LICENSES, PERMITS AND WORKERS' COMPENSATION COVERAGE, AND I <br /> CERTIFY THAT THE NFORMATION PROVIDED IS TRUE AND CORRECT. <br /> Signatur� <br />
The URL can be used to link to this page
Your browser does not support the video tag.