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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 insmance 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. Fmthermore, 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 insuranceagent) <br /> <br />'TJ 6 ,'SfIlCJAL \\.1 <br />~ ItJ4cJ 0 '0 <br />JjJZ--!- ~C)Ol. To--1I...z.tJ,2t;03 <br />(OR) <br /> <br />Policy Number: <br /> <br />Dates of Coverage: <br /> <br />I am not required to have workers' comp"ensation 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 />Business Address: <br /> <br />I certify that the information .~.t> .. and complete and that a valid <br />workers' compensation policy will be kept in effect at all times as required by law. <br />Name: ~ fi en.} FLJ71..JC is V It N O-t i R ('p c-( <br />[First] [Middle] [Last] <br />Name of Business: 1/1/6(:- 6v'iS P,?" ZA ilJ" f <br />7CJ 9S" ~ () 11-1- A1/-e- 5 <br />Le/J rer8l1 t,(k' rn Ai SSo J J <br />[City] [State] [Zip] <br />(,5i- "H-IG1(7 d,,-:/./" " .d '" <br />j'~/3-()3 ~~ <br />Date Signature <br /> <br /> <br />.. <br /> <br />Business Phone: <br />