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<br />CERTiFICATE OF COMPLIANCE <br />MINNESOTA WORKERS' COMPENSATION LAW <br /> <br />Minnesota Statilte, 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 of MSS 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 agent) <br /> <br />'\='eD~n <br /> <br />Policy Number: <br /> <br />tr1 L~'Sl.. \ <br />~W o'J> TO '2.' \ l \'II i..j <br />(OR) <br /> <br />Dates of Coverage: <br /> <br />I am not required to have workers I compensation liability coverage because: <br /> <br />o <br /> <br />I have no employees <br /> <br />D <br /> <br />I am self-insured (include permit to self-insure) <br /> <br />D <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 informatio <br />workers I compensation policy Wl <br /> <br /> <br />rate and complete and that a valid <br />e kept in effect at all times as required by law. <br /> <br />Name: <br /> <br />~- <br />00"0 <br />[First] <br /> <br />M\.c...~ <- <br />[Middle] <br /> <br /><;:,if-fcs't-J .' <br />[Last] <br /> <br />Name of Business: <br /> <br />~~ ~)G~">> <br /> <br />Business Address: <br /> <br />\q,\o ..","A-~N s\ _ <br /> <br />~~It.....J"~~ <br />[City] <br /> <br />('-'\.1\oJ S ~o ~ ~ <br />[State] [Zip] <br /> <br />~1:1 \'L"> ~ o'} <br />Date <br /> <br />IoS;" i..\ -u.. - ~ c..oe. <br /> <br />~ <br /> <br />Business Phone: <br />