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2010 TREE REMOVALS WITH VEHICULAR ACCESS 4 <br /> <br />PROOF OF WORKERS’ COMPENSATION <br />INSURANCE COVERAGE <br /> <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 /> <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 /> <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 /> <br />INSURANCE COMPANY NAME: ______________________________________________ <br />(NOT the insurance agent) <br /> <br />POLICY NO. OR SELF-INSURANCE PERMIT NO.: _______________________________ <br /> <br />DATES OF COVERAGE: ____________________________________________________ <br /> <br />- OR – <br /> <br />I am not required to have workers’ compensation liability coverage because: <br /> <br /> I have no employees covered by the law. <br /> <br /> Other (specify): ________________________________________________ <br /> _____________________________________________________________ <br /> <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 /> <br /> <br /> ________________________________ <br /> (Signature)