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_ _ _ � � ��u��l� � V 02 <br />�� � �: � ..:. � �' � ...� 4 �: <br />I ::. � � ��' ' � - <br />N1i�n�sof� Siatut�, S�tiora 1 i�.�2 r�qutr�s �ver�r ���t� an� I�ca9 lace��ing �g�r��y to <br />v�rithh�ld the i�uartc� or r�r���eal of a licer�se e�r p�srr�tif fo op�r�t� a�usines� oe �ngage <br />in an activi�y in �lnn�sota until the applicant p��s�r�ts acceptable �vidence �f <br />campt�ar�c� �i�h fhe 1lVork�rs' Comp�nsa#aon insuranc� coverag� �e��irer�i�nt of MSS <br />Ch$pt�r �76. The infot°rraation required �s: 4h� n�rne of the instarancg corr�pany, fh� <br />p�licy n�mber,,and d�te� vf coverage or the perrn� to s��f-ir�sure. 'T�ais °srt�ormatian �rfll <br />be c411ected b�@�a� licenstn a etc and re�air�ed in thei �ies. <br />�`his'inf�rmation is requfr�d by law, �nd licenses �r�d perrrtits io op�rafe a business may <br />noi b� l�sued or re��wed if it is no# provided a�tdl�r is f�i��fy sfa#�d, it may r�sult in <br />�1,(�0 penalty ass�sse� against �h� app'icar�t �y th� C�mrnissior�er af the Departmene <br />df Labor ar�d lndustry. ' � <br />ir�surar�ce G�m�aa�y Alarne: <br />(hlO� the tnsura�c� ag�r�A) <br />Policy�#: <br />Dates �f Cover��e: �o <br />t am not ��qe�ir�d to h�ve �1ior�cers' Campen�a#ion Ii�bili�y coverage becaus�: <br />{ ) I ha�e no empioy8�s <br />( ) ! am self �nsured {includ� �ermit to self-insure} <br />{) t have na �mpd�y�es w►hv are covered �y ti,� VV��e�s° �omp�r�sation law (ihese <br />it�cla�d� spv�se, parents, children, and certain f�rr� employe�s) <br />I certify tha� the informatlar� p�ovided abov� is ac��raf� and compiei� and that a valid <br />VVoa�cers' C�rnpensa#ia� policy wll! be kepi in eff�ct at a11 tim�s as req�ired by �aw. <br />NAME: <br />(las#, f�rst, middie} <br />DOtNG �l1�IN��S AS: <br />(bus►ness narne if different �han yc��ar s�ame) <br />�USIN�SS A�D�ESS: <br />C(T!', �iATE, �li�: � <br />PHONE: ( ) , - — <br />; ��� �. <br />; <br />