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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 information required <br />is: the name ofthe 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 />Policy Number: <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 />~F~jJ ,1Jl~ <br />- ~lf/f~, &0 1 <br />7t*~ TO ,*rQ~t <br /> <br />Insurance Company Name: <br />(NOT the insurance agent) <br /> <br />Dates of Coverage: <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 />JiI!---1 am self-insured (include permit to self-insure) <br /> <br />D 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: Cu~ {) ( <br />rrst] [Middle] <br />;So! m~ U: <br /> <br />g <br /> <br /> <br />[Last] <br /> <br />Name of Business: <br /> <br />Business Address: <br /> <br />(!~ ~ !)O?JS?? <br />[City] ) [State] [Zip] <br />Business Phone: ~~/-tj',Jla~ <br />I !/{l5~6- I~ <br />Date Signature <br /> <br /> <br />4~ <br />