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<br />CERTIFICATE OF COMPLIANCE <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 of MSS Chapter 176. The infonnation 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 infonnation 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 />infonnation 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: <br />(NOT the insurance agent) <br /> <br />Policy Number: <br /> <br />Dates of Coverage: <br /> <br />TO <br /> <br />. I <br />. i <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 />o <br /> <br />I am self-insured (include permit to self-insure) <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: ~fl~,Jtt 71,a;1t1fS .S46~ <br />[First] [Middle] [Last] <br /> <br />Name of Business: .sAh{~~ 1lA~,., IV' 61;Ill <br /> <br />Business Address: 709ft; (6#lt/h/lut IPOAIJ <br /> <br />Ltfi-{VJ 1I1bLC J41l1. <br />[City] [State] <br /> <br />9/ <br /> <br />S'JoJ~ <br />[Zip] <br /> <br />10-/h-07 <br />, <br />Date <br /> <br /> <br />Business Phone: <br />