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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: 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 infonnatioo is required by law, and licenses and pennits to operate a business may oat be <br />issued or renewed if it is not provided and/or is falsely reported. Furthermore, 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 ofuibor and Industry. <br /> <br />Insurance Company Name: <br />(NOT the insurance agent) <br /> <br />BIAC <br /> <br />Policy Number: <br /> <br />we - ~Z- 0.4-- I r~ 7 Z~ -OJ <br /> <br />Dates of Coverage: <br /> <br />l(b!1-c6r <br /> <br />TO 1/6/:;eo ~ <br />{ r <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 />Ihave 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: <br /> <br />M(t/fuel <br />[First] <br /> <br />Tko II/t4-f <br />[Middle] <br />{fh-l 4",.'11~ <br />709 3 ?O~ <br /> <br />Ce'1~,:lk <br />[City] <br />C51. l.{ U 'C67~ <br /> <br />it'? vC/r <br />A~ 5 <br /> <br />wAtA#- <br />[Last] <br /> <br />6cz,;/<2 ( <br /> <br />Name of Business: <br /> <br />Business Address: <br /> <br />}ltJJ <br />[State] <br /> <br />~3;- <br />[Zip] <br /> <br />Business Phone: <br /> <br />(0 .~/. 7 <br />Date <br /> <br /> <br />Signature <br />