Laserfiche WebLink
<br />,~ <br /> <br />,~ <br /> <br />CERTIFICATE OF COMPLIANCE <br />MINNESOTA WORKERS' COMPENSATION LAW <br /> <br />" ' <br /> <br />MDm.esot8.,Statute,.Section 176.182 requires every state and loCalliceiJsing agency to withhold, <br />the issuance or'renewal of a license or permit to operate a business or engage in an ~ in <br />Minnesota until the applicant ~ acceptable eviden~ of compliance with the workers' <br />coriJ.pensation insuIaBCe cOverage requirements ofMSS Chapter 176. The information iequired <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 recpiired 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 :fi11sely reported. Furthermore, if this <br />iDformati.on is not provided or fidsely stated, it may result in a $1,000 penalty asSessed against <br />the applicant by the Commissioner of the Department of Labor and Industly. <br /> <br />-- <br />InsuranceC01IIfJ01IYName: .;p-~ .v~~a-. <br />(NOT the insurance agent) <br /> <br />Dates of Coverage: <br /> <br />-, ~'3"2. t <br /><2-\ \ \ 0'+ 2..1 & los <br />TO. <br /> <br />Policy Number: <br /> <br />(OR) <br /> <br />I am not required to have wQ1'kers' compensation liability coverage because: <br /> <br />o <br />o <br />0' <br /> <br />I have no employees <br /> <br />I am self-insured (include permit to self-insure) <br /> <br />I have no employees who are covered by the wmkers' compensation law <br />(these include: spouse, parents, children and certain farm employees) <br /> <br />I certify that the irformation provided above is DCC'III'ate and complete and that a valid <br />workers' compensation policy will be kept in effect at all times as required by law. <br /> <br />Name: <br /> <br />,--\ o~ <br />[First] <br /> <br />K,C:~,,- <br />[Middle] <br />~~ '6c~s <br />\'1~o M~, ~- <br />~\)Jo. <br />[City] <br />1dS\ ~ 'U., <br /> <br />~ <br />[Last] <br /> <br />Name of Business: <br /> <br />Business Address: <br /> <br />Business Phone: <br />\\\,\d-\ <br />Date <br /> <br />M~, <br />[State] <br />(,,(,OB <br /> <br />S'SD 1>5 <br />. [Zip] <br /> <br />~ <br />