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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 infonnation required <br />is: tbe 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 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 andlor is falsely reported. Furthennore, 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: <br />(NOT the insurance agent) <br /> <br />-Yii~-r \)~ :t:1\06lw\1\..i; ~~ <br /> <br />Policy Number: <br /> <br />UC2..o0- Ot)"C) "3sQ) - DC> <br /> <br />Dates of Coverage: <br /> <br />"l}O"1. <br /> <br />. <br /> <br />TO <br /> <br />~JOB <br /> <br />(OR) <br /> <br />I 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 fann 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 />I Dot) <br />[First] <br /> <br />Ml~ <br />[Middle] <br /> <br /><;~ <br />[Last] <br />?1U>Pe..LtCG1 I j:"c.. n"GA <br />tot\.. A..~ S- <br /> <br />, <br />Wt~~ <br /> <br />Name: <br /> <br />Business Address: <br /> <br />~..~ <br />70lis <br /> <br />Name of Business: <br /> <br />Business Phone: <br /> <br />1611l.lcl <br />Date <br /> <br />C~~,~~ <br />[City] <br />losl t,S~ <br /> <br />rv\~ <br />[State] <br /> <br />lD17 <br /> <br />S So2> tb <br />[Zip] <br /> <br />