2005-11-09 CC Packet - Laserfiche WebLink

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CERTIFICATE OF COMPLIANCE MINNESOTA WORKERS' COMPENSATION LAW Minnesota Statute, Section 176.182 requires every state and local licensing agency to withhold the issuance or renewal of a license or pennit to operate a business or engage in an activity in Minnesota until the applicant presents acceptable evidence of compliance with the workers' compensation insurance coverage requirements ofMSS Chapter 176. The information required is: the name of the insurance company, the policy number, and dates of coverage, or the pennit to self-insure. This information will be collected by the. City and retained in the files. This information is required by law, and licenses and permits to operate a business may not be issued or renewed if it is not provided and/or is falsely reported. Furthermore, if this information is not provided or falsely stated, it may result in a $1,000 penalty assessed against the applicant by the Commissioner oftbe Department of Labor and Industry. Insurance Company Name: (NOT the insurance agent) ~c-,d, ~ / -1- Ob TO /)."3/'0(;, Policy Number: Dates of Coverage: (OR) I am not required to have workers' compensation liability coverage because: o I have no employees o D I am self-insured (include permit to self-insure) I have no employees who are covered by the workers' compensation law (these include: spouse, parents, children and certain farm employees) I certify that the information provided above is accurate and complete and that a valid workers' comp 'on policy will be kept in effect at all tim as required by law. Name: -t/L [First] _~_ [Mi e] [Last] Name of Business t:J[)tf/l/U;1(} ~ J,.., ()/j ~~~: etl! JCi~ [State] [Zip] Business Phone: (PSI- J-6!- ;J/1!_~ /)J/J. /_ //-;--02' ~ Date Signature Business Address: /0/