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<br />, <br />. <br /> <br />" <br /> <br />CEKl'I}lCATE OF COMPLIANCE <br />MINNESOTA WORKERS' COMPENSATION LAW <br /> <br />Minnesota S~ Section 176.182 requires every state and local liCAnlUttg agency to withhold <br />the ,issuan~ or renewal of a license or permit to opeflIte a,bnmneB or engage in an ~ in <br />~esota until the applicant presents acceptable evidence of compliance with the wmkers' <br />compensation insurance covemge requirements ofMSS Ch8pter 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 collectecl'by the City and retBined in the files. <br /> <br />This information is required by law, and licenses and permits to operate a businP.!L~ may not be <br />issued or renewed if it is not provided and/or is fi1lsely reported. Futtbermore, if this <br />information is not provided or falsely stated, it may result in a $1,000 penalty assessed against <br />the applicant by the Coinmissioner oftbe Deparbnent of Labor and Industry. <br /> <br />Insurance Company Name: <br />amI the insurance agent) <br /> <br />Policy Number: . <br /> <br />Dates of Coverage: <br /> <br />~J )1l6 TO IJ' -:J{lJ,) <br />(OR) <br /> <br />I am not required to have workers' compensation liability coverage because: <br /> <br />o <br /> <br />I have no employees <br /> <br />I am self-ins1.n-ed (include permit to self-insure) <br /> <br />o <br />o <br /> <br />I have no employees who are covered by the workers' compensation law <br />(these include: spouse, parents, children and certain farm. employees) <br /> <br />1 certify that the iTiformation provilkd above is accurate and complete and that a valid <br />workers' compensation pOlicy will be kept in tiffect at all times a$ required by law. <br /> <br />Name: <br /> <br />[First] <br /> <br />[Middle] <br /> <br />[Last] <br /> <br />Name of Business: <br /> <br />Business Address: <br /> <br />[city] <br /> <br />[State] <br /> <br />[Zip] <br /> <br />Business Phone: <br /> <br />Date <br /> <br />Sig11ature <br />