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CERTIFICATE OF COMPLIANCE MINNESOTA WORKERS' COMPENSATION LAW 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 requirements ofMSS Chapter 176. 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 City and retained in the 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 $1,000 penalty assessed against the applicant by the Commissioner of the Department of Labor and Industry. Insurance Company Name: iliOT the insurance agent) Policy Number: Dates of Coverage: TO (OR) I am not required to have workers' compensation liability coverage because: o I have no employees o I am self-insured (include permit to self-insure) o I have no employees who are covered by the workers' compensation law (these include: spouse, parents, children and certain farm employees) I certify that the information provided above is accurate and complete and that a valid workers' compensation policy will be kept in effect at all times as required by law. Name: M;!&~ ;:[;apyn~ [First] [Middle] Name of Business: ~ 1/1/ /.5 ~ /" ,J ~ .,- / '}tJlS' ~ a~/fri/c'llc !l~f~';I//f /I!,./ [City] bf/"~:5'.3- ?/Z) .~/ c--)~k [Last] Business Address: y: ~G. ~ 55.?73~ [Zip] [State] Date J)~/ ~ ~ c0~ Signature Business Phone: &d 2},