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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 ~pplicant presents acceptable evidence of compliance with the workers' <br />compensation-insurance coverage requirements ofMSS Chapter 176. - The information 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 />~ <br />rG?D~fV\~O <br /> <br />Insurance Company Name: <br />(NOT the insurance agent) <br /> <br />Policy Number: <br /> <br />Dates of Coverage: <br /> <br />I-8M -F~ -4q1\q <br /> <br />o. ~:, 'Z...l <br />"l..h\u,= TO "2..11ltCo <br /> <br />(OR) <br /> <br />o <br /> <br />I am not required to have workers' compensation liability coverage because: <br /> <br />I have no employees <br /> <br />o <br />o <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 />~ <br />Name: ~{")()O <br />[First] <br /> <br />*'^"~L <br />[Middle] <br /> <br />c.oVW\.tn'-- 'E)Qi'us S <br /> <br />Name of Business: <br /> <br />~~~6tJ <br />[Last] <br /> <br />Business Address: <br /> <br />t ~~ c.> <br /> <br />, <br />M- i\- ,.... c;1'"' - <br /> <br />~"fl\rz.:\ {( &, <br />[City] <br /> <br />Business Phone: <br /> <br />&- ~ l ...f u.-. <br /> <br />\Ol~\ oc; <br />Date <br /> <br />~)o3 ~ <br />[Zip] <br /> <br />V"\,....> <br /> <br />[State] <br /> <br />v{.,D<<6 <br /> <br />~ <br /> <br />1,1. <br />