Laserfiche WebLink
<br />CERlllfICATE.OF COMPLIANCE <br />MINNESOTA WORKERS' COMPENSATION LAW <br /> <br />. <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 opemte a business or engage in an ~ in <br />. :Minnesota until the applican1: presents acceptable evi~ce of compliance with the wmkers' <br />compensation insurance coverage requirements ofMSS Chapter 176. The information required <br />. is: the name of the ilisurance company, the policy number, and dates of coverage, or the perinit <br />to self-insore. This information will be collected by the City and rWtined in the files. <br /> <br />This information is required by law, and licenses and pCimitsto operate a business may not be <br />issued or renewed if it is not provided and/or is falsely reported.. FU1'thepnore, 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 />~ /: T !J,w.tr SUt1eP I}K.,. <br />Insurance Company Name: dCf-fC('o JnSIIVlu;e:I!. ... <br />(NOT the insurance agent) <br /> <br />Policy Number: <br />. Dates of Coverage: <br /> <br />02'" ~P-l3tj79()-IO <br /> <br />17/fli/O'l TO 67/n/dr <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 />5'17) J ~ <br />[Zip] <br /> <br />/6 - 'J-f'-oY <br />Date <br /> <br />, <br />