Laserfiche WebLink
<br />CERTIFICATE OF COl\1PLIANCE <br />MINNESOTA WORKERS' COMPENSATION LAW <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 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 coverage requirements ofMSS Chapter 176. The information required <br />is: the name of the insurance 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 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 falsely reported. Furthermore, 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 /> <br />Insurance Company Name: fq - It' -I / >l/f Tt; "'- <br /> <br />(NOT the insurance agent) <br /> <br />Policy Number: <br /> <br />(j 2- B p 'J- '3 97 .1 () 3 0 <br /> <br />Dates o/Coverage: <br /> <br />U I I (", I 0 7 <br /> <br />TO tZ.!Jt / ()/l <br /> <br />(OR) <br /> <br />1 am not required to have workers' compensation liability coverage because: <br /> <br />o <br /> <br />I have no employees <br /> <br />o <br /> <br />I am self-insured (include permit to self-insure) <br /> <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 />I certify that the information 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 /> <br />Name: <br /> <br />Jv1 ~{,.Ilu { <br />[First] <br /> <br />Tt+UMAf <br />[Middle] <br />{ 0t. .J-e,Yv/ I { e LeI f/tJ v <br />709'5 201\ Au- 5' <br /> <br />C'e~ ./-vv-v/ ( ie <br />[City] <br />eft -l{}.6. 6G7'1 <br /> <br />\Ai kv 10A'1t. <br />[Last] <br /> <br />r] v,;~ I <br /> <br />Name of Business: <br /> <br />Business Address: <br /> <br />M.t\; <br />[State] <br /> <br />f;O ~ <br />[Zip] <br /> <br />Business Phone: <br /> <br />I~- (P<,0 <br />Date <br /> <br /> <br />t1: <br />