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<br />CERTlllCATE OF COMPLIANCE <br />MINNESOTA WORKERS' COMPENSATION LAW <br /> <br />Minnesota Stafute, 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 insmance 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-insme. 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 Department of Labor and Industry. <br /> <br />Insurance Company Name: <br />(NOT the insurance a~ent) <br /> <br />Policy Number: <br /> <br />Dates of Coverage: <br /> <br />TO <br /> <br />(OR) <br /> <br />I am not required to have workers · compensation liability coverage because: <br /> <br />D <br /> <br />I have no employees <br /> <br />D <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 />I certify that the information provide_ complete and that a valid <br />workers' compensation policy will be ~es as lCequired by law. <br /> <br />Name: -1Ne/JtfIJU ~1JII[5 5466/1 <br />, [First] 1Middle] [Last] <br /> <br />Name ofBusiness:SAbtt 5 ~ &JO/f <br /> <br />71J9 ~ Jl)tJ Avl. 50. <br /> <br />ttJ1l1i'AJ/lt t <br />[City] <br /> <br />/51- <br /> <br />Business Address: <br /> <br />JM {fi/, <br />. [State] <br /> <br />,J.J'v38 <br />[Zip] <br /> <br />Business Phone: <br /> <br /> <br />J 67i <br /> <br /> <br />- )tJ-)--OJ <br />Date <br />