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<br />2010 ROOF MANAGEMENT PROGRAM/ROOF REPAIR ADMINISTRATION 4 <br />CITY PROJECT NO. 2010-004 <br />PROOF OF WORKERS’ COMPENSATION <br />INSURANCE COVERAGE <br />Minnesota Statutes Section 176.182 requires every governmental subdivision entering into a contract for <br />doing any public work to obtain acceptable evidence of compliance with the workers’ compensation <br />insurance coverage requirement of Minnesota Statutes Section 176.181, subdivision 2. This information <br />will be furnished, upon request, to the Department of Labor and Industry to check for compliance with <br />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 not be entered into <br />if it is not provided or is falsely reported. Furthermore, if this information is not provided or is falsely <br />reported, it may result in a penalty assessed against your business by the Commissioner of the Department of <br />Labor and Industry. <br /> <br />Provide the information specified above in the spaces provided, or certify the precise reason your business is <br />excluded from compliance with the insurance coverage requirement for 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 /> <br />- OR - <br /> <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 /> <br /> <br />I HAVE READ AND UNDERSTAND MY RIGHTS AND OBLIGATIONS WITH REGARD TO <br />PUBLIC CONTRACTS AND WORKERS’ COMPENSATION COVERAGE, AND I CERTIFY THAT <br />THE INFORMATION PROVIDED IS TRUE AND CORRECT. <br /> <br /> <br />________________________________ <br />(Signature)