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<br />-:- <br /> <br />.CEKfD1CATEOF COMPLIANCE <br />MINNESOTA WORKERS' COMPENSATION LAW <br /> <br />Minnesota Statute, Section 176.182 requires every state and local licensing agency to withhold <br />the isswu1ce 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 covemge requirements ofMSS Chapter 176. The information required <br />is: the:name of the insurance company, the policy number, and dates of covemge, or the permit <br />to self-insure. This information will be collected by the City and fehainM 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 :fidse1y reported. Furthermore, if this <br />information is not provided or fi1lsely stated, it may result in a $1,000 penalty assessed against <br />the applicant by the Commissioner of the Department of Labor and Industry. <br /> <br />Insurance Company Name: ].:Sf.. r Il ( & y J1J. V/1l f ,J 161'-11- t D~!r. <br />(NQI the insurance agent) <br /> <br />Dates of Coverage: <br /> <br />01.( - 13 f>3 3:$ - 02.- <br />6 J, J () 1I To;f / 9 / #S <br /> <br />, # , ." <br /> <br /> <br />(OR) <br /> <br />Policy Number: <br /> <br />I am not required to ht:ive workers' compensation liability coverage because: <br /> <br />D <br /> <br />I have no employees <br /> <br />D <br /> <br />I am self-insured (include permit to self-insure) <br /> <br />D I have no employees who are covered by the workers' compensation law <br />(these include: spouse, parents, children and certain farm. employees) <br />1 certify that the itiformation provided above is accurate and complete and that a valid <br />workers' compensation policy will be kept in effect at all times as required by law. <br />Name: JA1j I, ~ ;:(i./ltnn t 13-J.$~k <br />[First] [Middle] [Last] <br />Name of Business: 1&//" S )~~~f/', J:'/II~. <br />~ <br /> <br />Business Address: I)/) '/3.. c;.", If /'tJ; I ~ fJJ <br />c''''fEY"tll/h /11,.) d~/)53 <br />[City] [State] [Zip] <br />Business Phone: UI-t-5~-?~9~ . <br />IP/31/tW _-_- .-. a~:.1 <br />Date Signatu11 <br />