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Insurance (ATTACH CERTIFICATE OF INSURANCE TO THIS FORM) <br />Licensee must obtain one of the following PER Minnesota Statute 340A.409: <br />Check one: <br />$A. Liquor Liability Insurance (Dram Shop) - $50,000 per person, $100,000 more than one person; $10,000 <br />property destruction; $50,000 and $100.000 for loss of means of support. <br />Please review Insurance Certificate before submitting: <br />Must be Certificate of Insurance (Declarations or Binders not accepted) <br />Licensee name on this application and the Insurance Certificate must match EXACTLY. <br />Must provide physical address of licensed location (No PO Boxes accepted) <br />Dates of coverage must cover the entire license period. <br />or <br />' ❑ B. A surety bond from a surety company with minimum coverage as specified in A. <br />or <br />$ C. A certificate from the State Treasurer that the licensee has deposited with the state, trust funds having <br />market value of $100,000 or $100,000 in cash or securities. <br />Minnesota Statutes, Section 176.182 requires every state and local licensing agency to withhold the issuance or renewal of a license or <br />permit to operate a business or engage in any activity in Minnesota until the applicant presents acceptable evidence of compliance <br />with the workers' compensation insurance coverage requirement of Minnesota Statutes, Chapter 176. The required workers' <br />compensation insurance information is the name of the insurance company, the policy number, and the dates of coverage, or the <br />permit to self -insure. If the required information is not provided or is falsely stated, it shall result in a $2,000 penalty assessed against <br />the applicant by the commissioner of the Department of Labor and Industry. A valid workers' compensation policy must be kept in <br />effect at all times by employers as required by law. <br />Workers compensation insurance company: Name <br />Policy # <br />Number of employees: <br />I certify that I have read the above questions and that the answers are true and correct of my own knowledge. <br />Print name of applicant & title Signat of App t Date <br />� to) Cal <br />n t << <br />PS 9136-(2012) <br />