2023-03-14 P & Z Packet - Laserfiche WebLink

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Form #3 MINNESOTA WORKERS’ COMPENSATION LIABILITY CERTIFICATE OF COMPLIANCE Minnesota Statute, Section 176.182 requires every state and local licensing agency to withhold the issuance or renewal of a license or permit to operate a business or engage in an activity in Minnesota until the applicant presents acceptable evidence of compliance with the workers’ compensation insurance coverage requirement of Chapter 176.181. The information required is: the name of the insurance company, the policy number, and dates of coverage or the permit to self-insure. This information will be collected by the licensing agency and retained in their files. This information is required by law, and licenses and permits to operate a business may not be issued or renewed if it is not provided and/or is falsely reported. Furthermore, if this information is not provided or falsely stated, it may result in a $2,000 penalty assessed against the applicant by the Commissioner of the Department of Labor and Industry. Insurance Company Name: *Note: This is NOT the insurance agent. Telephone Number: Policy Number: Dates of Coverage:*Note: If not continuous, dates of coverage must correspond EXACTLY with the license period; i.e., January 1 - December 31. I am not required to have workers’ compensation liability coverage because: I have no employees. I am self-insured (include permit to self-insure). I have no employees who are covered by the worker’s compensation law (these include: Spouse, Parents, Children and certain farm employees). Personal Information: First Name: Middle Name: Last Name: Doing Business As: Name: Street: City: Address of Business: State: Zip: Phone Number: I certify that the information provided above is accurate and complete and that a valid worker’s compensation policy will be kept in effect at all times as required by law. Date:_______________________Signature:__________________________________________