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<br />CERTlFICATE OF COMPLIANCE <br />MINNESOTA WORKERS' COMPENSATION LAW <br /> <br />Millnesota Statute, Section 176.182 requires 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 requirements ofMSS Chapter 176. The information required <br />is: the name of the insurance company, the policy number, and dates of coverage, or the permit <br />to self-insure. This information will be collected by the City and retained in the files. <br /> <br />This information is required by law, and licenses and permits to operate a business may not be <br />issued or renewed if it is not provided and/or is falsely reported. Furthermore, if this <br />information is not provided or falsely stated, it may result in a $1,000 penalty assessed against <br />the applicant by the Commissioner of the Deparbnent of Labor and Indus1ry. <br /> <br />Insurance Company Name: <br />(NOT the insurance agent) <br /> <br />_1?:,~ r ILl c. d <br />I <br /> <br />fJ(.)VM'~tlJ J~ tl'd- .(-Df'S <br /> <br />Policy Number: <br /> <br />we.- Z.Z" 01./ -- '30355..0 <br /> <br />Dates of Coverage: <br /> <br />!5 19ft) 3 <br /> <br />TO 5/') /tJ.I/ <br />. <br /> <br />(OR) <br /> <br />I am not required to have workers' compensation liability coverage because: <br /> <br />o <br /> <br />I have no employees <br /> <br />o <br />o <br /> <br />I am self-insured (include permit to self-insure) <br /> <br />I have no employees who are covered by the workers' compensation law <br />(these include: spouse, parents, children and certain farm employees) <br /> <br />Name of Business: <br /> <br />I certify that the information provided above is accurate and complete and that a valid <br />workers' compensation policy will be kept in effect at all times as required by law. <br /> <br />Name: !J/;;"'Ht ~ J3IS~~ <br />[First] [Middle] [Last] <br /> <br />)4.//'1 ~ Jd~A(;r, ~~ <br />~~ '1<1 - ~ I~/"t/I//~ <br />c~ Ivl"/~ /II,,) <br />[City] [State] <br />~;"/ - /'53 - <br /> <br />JV <br /> <br />Business Address: <br /> <br />5:1'.(/ J i' <br />[Zip] <br /> <br />//)~ph3 <br />/ Date <br /> <br />?P~ <br />-fli3-~ <br />Signature . <br /> <br />Business Phone: <br />