CCP 07-13-1998 - Laserfiche WebLink

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CERTIFICATION OF COMPLIANCE MINNESOTA WORKERS' COMPENSATION LAW ., 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 or engage in an activity in Minnesota until the applicant presents acceptable evidence of compliance with the workers' compensation insurance coverage requirement of Chapter 176. The information required is: the name of the insurance company, the policy number, and dates of coverage or the permit to self-insure. This information will be collected bv the licensinl!: al!:ency and retained in their fiI es. This information 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 is falsely reported. Furthermore, if this information is not provided or falsely stated, it may result in a $2,000 penalty assessed against the applicant by the Commissioner of the Department of Labor and Industry. Insurance Company Name: ~p ~I~ \ ~ ~v-;,l>"I.-\ ~ (NOT the insurance agent) Policy Number 9 ~ -11- ~\ Dates of Coverage: b. 1fK t~ ::r-~J -78 to =?-~ I --- '11 . (or) I am not required to have workers' compensation liability coverage because: (>Q I have no employees ( ) I am self.insured (include permit to self-insure) ( ) I have no employees who are covered by the workers' compensation law (these include: Spouse, Parents, Children and certain farm employees) -...>;<...- I certify that the information provided above is accurate and complete and that a valid workers' compensation policy will be kept in effect at all times as required by law. Name: /VJ vy-ev... ++lA~ J~",~ (last, IrSt, middle) Doing Business As: Na,; Ls 3000 (business name if different than your name) Business Address: 3~ TS IV. ~iYl5-fQV\ A "12. . City, State, Zip: A~o!e"" d;/!s . HI' 6SIU,. Phone: (tl2.) Lf'8 4-Lf71/ 4 Signature: 1rA/'1~~r----- Date: (".~09 - /' g ----.--------