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CERTIFICATION OF CC)iVII BANC E <br />MINNESOTA WC3RKE RS9 COMPENSATON LAW <br />Minnesota Stature, Section 176.182 squires every state and local licensing agency to withhold <br />the issuance or renewal of a license or permit to operate a business or engage in an activity in <br />Minnesota until the applicant presents acceptable evidence of compliance with the workers' <br />compensation insurance coverage requirement of Chapter 176. The information. required is: the <br />name of the insurance company, the policy number, and dates of coverage or the permit to self - <br />insure, This_inormation wiJ1 Ue collectedy tlr licensngancy and i_etai»ed in then_. files. <br />This information is required by law, and licenses andperniits to operate a business may n.ot be <br />issued or renewed if it is not provided anal/or is falsely reported. ;Furthermore, if this information. <br />is not provided or falsely stated, it may result in a 4$'2,000 penalty assessed against the applicant <br />by the Cornmissioner of the Department of Labor and Industry. <br />Insurance Company N <br />(NOT the insurance agent) <br />Policy N,aniber.'._.__f3—(– <br />Dates of Coverage:_ zb � _ to ._ L, -- <br />(or) <br />I am not regii-ed to have workers' compensation liability covorage because: <br />a I have no employees <br />❑ I am self-insured. (include permit to self -insure) <br />a I have no employees who are covered by the worker's compensation law (these include: <br />spouse, parents, children and certain farm employees) <br />I certify that the information provided above is accurate and complete and that a valid workers' <br />compensation policy will be kept in effect at all times as required by law. <br />Name: <br />Doing Business As: <br />(business name <br />Business Address: jj�. ��Laj�" , 371 <br />City, State <br />Si,ia CIL <br />than your, <br />Auenue Ae <br />Phone: <br />Date: i (- - (ao <br />M <br />