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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 permit 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 ofMSS Chapter 176. The inforination 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 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 />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 />H t<5r (J /fl< 0 'rFt' :rill /J -e m,v i r-y <br /> <br />(JJC 2.0 - 0 /J CJ~,;1..14 - () 0 <br />/1-2 <1- ~ TO J 1- 2'-J -..P5 <br />--~-- b {.I~h (OR) ---Jk-~.---- ~ <br /> <br />Policy Number: <br /> <br />Dates of Coverage: <br /> <br />I am not required to have workers' compensation liability coverage because: <br /> <br />o <br /> <br />I have no employees <br /> <br />D <br />D <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' compensation policy will be kept in effect at all times as required by law. <br /> <br />Name: Ke/111 e r11- <br />. <br />[First] <br /> <br />Fay:n.JG/.5 <br />[Middle] <br /> <br />Name of Business: /AI'/~e G y G/5 PI z,Zrr <br />/ <br />Business Address: '7 oct 5- C)..O 71"* )11/C <br /> <br />l~'rellVla~ mAl <br />[City] [State] <br />65/, "53-1077 <br /> <br />IO-2v-os ~~-~ <br />Date Signature <br /> <br />VllrlOellBeeJ( <br />[Last] <br /> <br />I tv C- <br />S <br /> <br />55"038" <br />[Zip] <br /> <br />Business Phone: <br /> <br />//5 <br />