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 permi t to operate a business in Minnesota unti I the applicant present s acceptable evidence of compliance with the workers' compensation insurance coverage requirement of Section 176.181, Subd. 2. The information required is: The name of the insurance company, the policy number, and dates of coverage or the permi t to self-insure. This information will be collected by the licensing agency and put in their company file. It will be furni shed, upon request, to the Department of Labor and Industry to check for compliance with Minnesota Statute Sec. 176.181. Subd. 2. This i nformat ion is requ ired by law, and licenses and permits to operate a business may not be issued or renewed if it is not provided and/ or is falsely reported. Furthermore, if this i nformat ion is not provided and/or falsely reported, it may result in a $1,000 penalty assessed against the applicant by the Corrrnissioner of the Department ! of labor and Industry payable to the Special Compensation Fund. Provide the information specified above in the spaces provided, or cert ify the precise reason your business is 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 OIlLIGATIONS WITH REGARDS TO BUSINESS LICENSES. PERMITS AND WORKERS' COMPENSATION COVERAGE, AND I CERTIFY THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT. (SIGNATURE) . JA/lc (J) 7/87