CCP 09-14-1987 - Laserfiche WebLink

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. . PROOF OF WORKERS' COMPENSATION INSURANCE COVERAGE . Minnesota Statute Section 176.182 requires every state and local licensing agency to withhold the issuance or renewal of a license or permit to operate a business in Minnesota unti 1 the appl icant presents acceptable evidence of compliance with the workers' compensation insurance coverage requirement of Section 176.181, Subd. 2. The i nformat i on requi red is: The name of the insurance company, the policy number, and dates of coverage or the permit to self-insure. This information wi 11 be co 11 ected by the 1 ;cens'i ng agenc.v and put in thei r company file. It will be furnished, upon request, to the Department of labor and Industry to cheCk for compliance with Minnesota Statute Sec. 176.181, Subd. 2. This informat ion is required by law, and licenses and permits to operate a business may not be issued or renewed if it is not provided and/or ;s falsely reported. Furthermore, if this information ;s not provided and/or falsely reported, it may result in a $1,000 penalty assessed against the applicant by the Commissioner of the Department lof labor and Industry payable to the Special Compensation Fund. Provide the information specified above in'the spaces provided, or certify the precise reason your business ;s excl uded from compliance with the insurance coverage requirement for workers' compensation. Insurance Company Name: (NOT the insurance agent) . Policy Number or Self-Insurance Permit Number: Dates of Coverage: (or) I am not required to have workers' compensation liability coverage because: ( ) I have no employees covered by the law. ( ) Other (Specify) I HAVE READ AND UNDERSTAND MY RIGHTS AND OIlUSATIONS WITH REGARDS TO BUSINESS LICENSES, PERMITS AND WORKERS' Cl>>lPENSATION COVERAGE, AND I CERTIFY THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT. (SIGNATURE) . JA/lc (J) 7/87 - ---------