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This inforration is required by law and a license or permit to operate a business may not be issued or renewed if information is not <br /> provided and/or is falsely reported. Further, if this information is not provided or is falsely stated,it may result in a$2,000 penalty assessed <br /> against the applicant by the Commissioner of the Department of Labor and Industry. <br /> Insurance Co.(not agent) tes of Coverage-From: To: <br /> C% MM/DD/YYYY0Z,/j 5/202�, MM/DD/YYYY �ll�(��12, <br /> rmat:MM/DD/YYYY Format:MM/DD/YYYY <br /> (OR) <br /> I am not required to have workers'compensation liability coverage because: <br /> ❑ 1 have no employees <br /> ❑ 1 am self-insured(include permit to self-insure) <br /> ❑ I have no employees wo are covered by the workers'compensation law(these include spouses,parents,children and certain farm <br /> employees) <br /> I certify that the information provided above is accurate and complete and a valid workers'compensation policy will be kept in effect at all times <br /> as required by law. <br /> Applicant Siganturr�e Company Name <br /> Date <br /> MM/DD/YYYY 01/28/2026 <br /> Format:MM/DD/YYYY <br /> Subrnit <br /> 2/2 <br />