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<br />I <br /> <br />. .. I <br />CERTD'lCATE OF COMPLIANCE <br />MINlUSOTA WOJIUlW COMRNSA'DONLAW : <br /> <br />"'111_. ..... SeGtfoD 176.182 WIl.a- 8VCIJ 8IIIID _1aa811P~ ~ &pIIGJ fD .JddwJd <br />tho ~-;...... or _.dd at a _ or permit fD apIIIII8 a 1,....J.I- or.... ill aD acIi9JIr ill <br />MI......... alii tho ~'I ,.~. IIIJ LqhllNA evfdmIae of w'.lIiAlIloIlA willa .. wvdt... <br />l!l(..A~ IIt!tLm ...,.....~ ~ .....h---.~... arMIS 0aPter 17'- Till "._.&...IMtI....~ <br />fa: ....... oftlla I...,.....,.. ~-~..,. ... po1iDJ ...,~ IIIiI1 cIaIIs at ~ or the ~ <br />fD se1f'-iIIsam. 'Dds 1.,....1>01,..... .. GD1Ia:IId" dlo aty ... ......... ill till" <br /> <br />TId& I..A.. .._lInn is &~~ ., Jaw. ami H(;I01I/j,A IIIId pamiIs fD opIIIdD a .....ft_may lICIt .. <br />..... or f4IIIIhtOC1 it II fa DOt pmvfdI4 aIIar ill .... f~ Fid~ if dlfs <br />....&_...Almt6 is IID1: pauYJdwl or 1tdsIJ,lIIIIIIId. it IIIaJ msaIt in a $1,000 JIIIIIII1J - - "ff apiIIst <br />dID W'lMtd" die c...It~'."""_I. attho Det-.I..~d ofLalm amI~. <br /> <br />TnsurtIntJB Ctmpn,y NfIIIIB: <br />OIl[ die L...a......., 8IfId} <br />Policy NrItIber. <br />IJtItes ofOwerage: <br /> <br />'J\,,\o~ TO \'1..\.. \0'""\ <br /> <br />(OR) <br /> <br />1 tlllllIDt rBfUb'ed to htzvs 1VtJ7JIn' Cl8IIpB1I8tIIID IItlbIlIIy COfB1Vlg8 ~ <br />o IbaYeDO empIay_ <br />I am se1f-hut..1iCI (IN:Iu4s ptII'IIIIt to BB{/-ItIBtJre) <br /> <br />o <br />o <br /> <br />I have DO ~_ who are co....~ by tie wOJLcm. "'"""'1-.'OJII Jaw <br />(1hese iIlc1uc1e: spo1ISI, pili'" chi1drcm 8DcI CIItIiD farm empIoy_> <br /> <br />1 certfIY that thB J)jb.,nfJIDn l1'ov1JlB4 ".". 18 tIIX:UJ"_1IIIIl cr11IIJIIf1Ie fIIItl tIttIt (I WIII4 <br />lVtR'ken' -..,-AStIIlmt po1It:ywlll be 1rI1pt In eJf<<:t fII tlll """118 required by 1tIw. <br />f'""'""l" r ~_ _ _ _ _ <br />NIIIIB: -.:::J OQO f'I\,~ ~ <br />. [Phst] [MicIdle] [Last] <br /> <br />Nameof~.ti,..: Sc.--U ~~4,_ J -r;,,~. b~ klsn:..~~ <br /> <br />:LsiDessAcldmss: ,~c; LO~~" s. <br /> <br />~~,\\~ ~~ c;~o~2> <br />[City] [S1afa] [ZiP] <br />lI~\ "'"t.0'& O\A '"L. ~~ \. 0-'\' <br /> <br />2.i... .. <br /> <br />.......~ Plume: <br />---1~"\01 <br />Date <br /> <br /> <br />~f <br />