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Certificate of Compliance <br />Minnesota Workers' Compensation Law <br />PRINT IN INK or TYPE. <br />Minnesota Statutes, Section 176.182 requires every state and local licensing agency to withhold the issuance or <br />renewal of a license or permit to operate a business or engage in any activity in Minnesota until the applicant <br />presents acceptable evidence of compliance with the workers' compensation insurance coverage requirement of <br />Minnesota Statutes, Chapter 176. The required workers' compensation insurance information is the name of the <br />insurance company, the policy number, and the dates of coverage, or the permit to self -insure. If the required <br />information is not provided or Is falsely stated, it shall result in a $2,000 penalty assessed against the applicant by <br />the commissioner of the Department of Labor and Industry. <br />A valid workers' compensation policy must he kept in effect at all times by employers as required by taw. <br />doing business as <br />name only It no company name used) I LlctNOtz UK rettiv0 i rvu pr appncaoie) <br />must <br />YOUR LICENSE OR CERTIFICATE WILL NOT BE ISSUED WITHOUT THE <br />FOLLOWING INFORMATION. You must complete number 1, 2 or 3 below. <br />NUMBER 1 COMPLETE THIS PORTION IF YOU ARE INSURED: <br />INSURANCE COMPANY NAME (not the Insurance agent) <br />NUMBER 2 COMPLETE THIS PORTION IF SELF-INSURED: <br />I have attached a copy of the permit to self4nsure. <br />NUMBER 3 COMPLETE THIS PORTION IF EXEMPT: <br />I am not required to have workers' compensation insurance coverage because: <br />I have no employees. <br />I have employees but they are not covered by the workers' compensation law. (See Minn. Stat. § 176.041 for a list of <br />excluded employees.) Explain why your employees are not covered: <br />Other: <br />ALL APPLICANTS COMPLETE THIS PORTION: <br />1 certify that the information provided on this form is accurate and complete. If 1 am signing on behalf of a business, I <br />certify that I am authorized to sign on behalf of the business. <br />NOTE: If your Workers' Compensation policy is cancelled within the license or permit period, you must notify the <br />agency who issued the license or permit by resubmitting this form. <br />This material can he made available In different forms, such as large print, Braille or on a tape. To request, call 1-800.342.5354 (DIAL -DLI) Volee or <br />TDD (651) 297-4198. <br />MN LIC 04 (11108)