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<br />CERTmCATE OF COMPLIANCE <br />MINNESOTA WORKERS' COMPENSATION LAW <br /> <br />MiPnesota Statute" Section 176.182 requires every state and loc:a1liccn.sing agency to vrithhold <br />the issuance at renewal of a Iicease or permit to operate a business or engage in an activity in <br />Minnesota umil the applicaot presents acceptable evidence of 1101l1p\iance with the workers' <br />c:ompeDSation insurance coverage requirements ofMSS Chapter 176. T!IIl information ~ <br />is: the DaDle of the insurance company, the policy number, 8Pd dates of c:overage, or 1he permit <br />to self..fusure. This information 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 />i99lled or renewed if it is not provided and/or is falsely reported.. Furthennore, if tbis <br />information is not provided or fil1sely stated, it may result in a $1,000 penalty assessed against <br />the appliamt by the Commissioner of the Dqlartrnent of Labor and TndustIy. <br /> <br />Insurance Company Name: <br />(NQI the insurance agent) <br /> <br />S,cM <br /> <br />Policy NU17Iber: <br />DaJes of Coverage: <br /> <br />O'2.~7 2.01 <br />S/"2.j, I 07 TO S /U / cYi <br />I I <br /> <br />(OR) <br /> <br />I am 1Iot required to have workers' compensation liability coverage because: <br /> <br />o <br />o <br />o <br /> <br />I have no employees <br /> <br />I am self-insured (illClude 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 Ihat the ;'!!ormation provided above ;s acCl/rate tmd complete and that a valid <br />workers' com~01l policy will be kept in effect at all times as required by law. <br /> <br />Name~~ L0p:l.Ylb ~1C)/USor..) <br />[First] [Middle] [Last] <br />, - . <br />Name ofBusmess: -"6=LU.f S ~ 1I~ ~~C) (Ll -:f'''-l(!.. <br /> <br />Business Address: .....2Q9..e. e~j'P7 QjJll.L'i ~. <br /> <br />Q.~~W'\1~((~ ^-U.l ~CJ4t <br />[City] . [State] [Zip] <br /> <br />Business Phone: .. l.D <br /> <br />( {:;--2., I 08 <br /> <br /> <br />-43- <br />