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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 pennit 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 information required <br />is: t1ie name of the insurance company, the policy number, and dates of coverage, or the permit <br />to self-insure. This infonnation 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 />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 />/7u~ -OW"'t?1<~ JNS'r/~Lc7 <br /> <br />Policy Number: <br /> <br />a6170IP-o!3d-I/038 <br />-=11 /0 7 TO;2- h./l? 8 <br />(OR) <br /> <br />Dates o/Coverage: <br /> <br />I am not required to have workers' compensation liability coverage because: <br /> <br />'I <br />I, <br />I' <br />I' <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' com ensation policy will be kept in effect at all times as required by law. <br /> <br /> <br /> <br />Name: <br /> <br /> <br />:=:=~]~j;~~ 1t <br />CP~~ /l;;U ,_r;soii <br />[City] [State] [Zip] <br /> <br />Business Phone: <br /> <br /> <br />- <br /> <br /> <br /> <br />/0 -;; i " 07 <br />Date <br />