CC PACKET 02221983 - Laserfiche WebLink

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ST.LOUI�S�PFRANCE f-374il s sV►�r of COMPLIANCE Wrm WORKEWS COMPENSATION acre TOTAL CHECK ; r the undersigned hereby states that (he) (she) (it) is in full oanpllance with DUE I G/�'DATE Minnesota Worker's CmWensation Act, M.S.A. 176.01 et. seq., and gives this DATE 112/CO-dam THRUs�12� Statement as evidence thereof as per Minnesota Statutes, Section 176.182. The undersigned hereby states 'that (he) (she) (it) carries workers compensation insurance in the amount of 6 ido,o-c o,o1' in compliance with ACCT.- GROCERY ACCT. MEAT ACCT. PRODUCE ACCT. BAKERY ACCT. EXPENSE Minnesota Statutes, Section 176.181 (2). s 0141 0142 0143 0144 The undersigned hereby states that if (he) (she) (it) is exempt from the 0241 0242 0243 0244 Minnesota Worker's Compensation Act for the following reason(s): 0341 0342 0343 0344 i 7hat the only persons engaged in the business are: 0441 0442 0443 0444 ! The partners, their spouses, parents or children, regardless of age; 0541 0542 0543 0544 or 0641 0642 0643 0644 The cxeejtive officer, who owns more than 258 of the stock, his or 0741 0742 0743 0744 her spouse, parents or children, regardless of age, of a closely 0841 0442 0843 oeaa held corporation with less than 22,880 hours of payroll per year; or 0941 0942 0943 0944 Persons whose employment is casual, and not in the usual course of toot 1042 1043 1044 the trade, business, profession or occupation of the undersigned; or 1141 1142 1143 1144 Persons employed by the corporation where those persons are related 1241 1242 1243 1244 by blood or marriage, within the third degree of kindred according to the rules of civil law, to All of the officers of the corporation 1341 1342 1343 1344 and the corporation has filed a written election with the 1441 1442 1443 1444 ! Commissioner of Labor and Industry to have those persons excluded from the Minnesota worker's Compensation Act; or 1541 1542 1543 1544 1641 1642 1643 1644 Other: (Cite Legal Authority) 1741 1742 1743 1744 1841 1842 1843 1941 1942 1943 1.344 2041 2042 2043 2044 The undersigned shall hold the City of Fridley harmless from any and all 2141 2142 2143 2144 damages and claims that may arise by reason of any injury to the undersigned, 2241 2242 2243 2244 (his) fher) (its) agents 2z La the performance of the contract with the City, and in case any action is brought therefore against the City of 2341 23421 2343 2344 Fridley, the undersigned shall assume full responsibility for the defense 2441 2442 2443 2444 thereof, and upon (his) (her) (its) failure to do so on proper notice, the City of Fridley reserves the right to defend such action and to charge all 2541 2542 2543 2544 costs thereof to the undersigned. 2641 2642 2643 2644 _ 1, Dated this .45d day of 2741 2742 2743 2744 2841 2842 28431 2844 2941 2942 2943 2944 3041 3042 3043 3044 ? Subscribed and sworn to before me 3141 3142 3143 3144 3241 3242 3243 3244 this day Of , 191, �pK o My°6 to 3341 3342 3343 3344 o• 3447- __. 3442,. 3443 3444 MAN 901%0 . 4/0/2/11