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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 />