Laserfiche WebLink
<br />. ... <br /> . <br /> PAGE 'IHREE I <br /> RUBBISH HAULERS APPLICATION <br /> - PROJF OF OORKERS' a:MPENSATION INSURANCE COVERAGE -- <br /> Minnesota statute Section 176.182 requires every state an:i local <br /> licensing agency to withhold the issuance or renewal of a license or I <br /> pennit to operate a l::usiness in Minnesota until the applicant presents <br /> acceptable evidence of compliance with the workers I compensation <br /> insurance coverage require.'l1e!1t of Section 176. 181, SUJ::d. 2, The <br /> infonration require:! is: The name of the insurance corrpany, the policy I <br /> nurnl:er, an:i dates of coverage or the permit to self-insure, This <br /> inforIl'ation will I:e collected by the licensing agency an:i put in their <br /> corrpany file. It will I:e furnished, upon request, to the Deparbnent of I <br /> Labor an:i Industry to check for compliance with Minnesota statute Sec. <br /> 176,181, Subd. 2. <br /> This infonration is require:! by law, an::l licenses an:i permits to I <br /> operate a l::usiness may not I:e issued or renewed if it is not provide:! <br /> an:i/or is falsely reported. Furthenrore, if this infonration is not <br /> provide:! an:i/or falsely reported, it may result in a $1,000 penalty I <br /> assessed against the applicant by the Commissioner of the Deparbnent of <br /> Labor an:i Industry payable to the Special Compensation Fund. <br /> Provide the infonration specifie:! l:elow in the spaces provide:!, or I <br /> ce....-tify the precise reason your b.1siness, is exclude:! from compliance <br /> with the insurance coverage require.'l1e!1t for workers' compensation. <br /> Insurance Company Name:Amer"Cc?h C<JJ'1lbense<nN7 InS". Co, " <br /> (Nor the insurance agent) / <br /> Policy N1.lnU:er or Self-Insurance Pennit N\.llr'l:er: Ac IJ COOr) 3'1:5- .3 I <br /> Dates of Coverage: 5-/- 9"/' - 5 - /- 97 <br /> I <br /> (or) <br /> . <br /> I am not require:! to have workers' compensation liability coverage . <br /> J::ecause : <br /> ( ) I have no employees covere:! by the law. . <br /> ( ) Other (Specify) <br /> . <br /> I <br /> I HAVE READ AND UNDERSTAND MY RIGHI'S AND OBLIGATIONS wrrn REGARDS 'IO I <br /> BUSINESS LICENSES, PERMITS AND OORKERS' a:MPENSATION COVERAGE, AND I <br /> CERI'IFY THAT THE INFORMATION PROVIDill IS TRUE AND CORRECI'. <br /> G\~ ~~"'~......% " I <br />I -- <br /> ( SIGNATURE) <br />I I <br />, <br />