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2003-11-12 CC Packet
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2003-11-12 CC Packet
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<br />CERTIFICATE OF COMPLIANCE <br />MINNESOTA WORKERS' COMPENSATION LAW <br /> <br />Minnesota 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 Department of Labor and Industry. <br /> <br />Insurance Company Name: <br />(NOT the insurance agent) <br /> <br />C2u~ otUllJef._<) ~ <br />o ~.)J/o 3% <br /> <br />6 <br /> <br />I-l~o'l TO lJ--JJLli <br /> <br />(PI <br /> <br />Policy Number: <br /> <br />Dates of Coverage: <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 />D <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 provided above is accurate and complete and that a valid <br />workers' compe ation policy will be kept in ~ffect at all ti~es as req~ired by l~. <br /> <br />Name: /1 . ~ J1h /I.J ~);LJ <br />[First] [Middle] [Last] <br /> <br />Name of Business: (!}lt7~~ &.:Ik~ '. &. iJM:n <br />O~ r-~~-/JJl ~~~i <br />70.ft- ~ ~ , <br />~.'t:e{ /J1~) 50030' <br />[City] [State] [Zip] <br />Business Phone: ?2:S 1- Cj.)(,. ;;.q:S ~/:J /; · <br />If) --/7- 03 ~/% ~ <br />Date Sigrtature.4 <br /> <br /> <br /> <br />Business Address: <br /> <br />
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