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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 inforrnationrequired <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 />5fA- J.'i dwr'c1 JfJ~ 1t-c-t1 '- <br /> <br />Policy Number: <br /> <br />d-2Z~/(P. ZO/ <br /> <br />Dates of Coverage: <br /> <br />m (4,'1 <br /> <br />2 ~() 5 TO /i1 J'ty C ~ i) I.:. <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 />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 />[First] <br /> <br />;:;[ <br />[Middle] <br /> <br />Name of Business: <br /> <br />)41!y ~ !6,/)rJ€t ~~ <br /> <br />/)tJt3 - Ce~/t,rhlh ~J <br /> <br />(;p;4ry,lle ;11;/ 5f~3g <br />[City] [State] [Zip] <br />k?L- t.5 3- tJfJ9 / ~ <br /> <br />~-~~ <br /> <br />Signature/ <br /> <br />Business Address: <br /> <br />Business Phone: <br />/ph/)t?f <br />, f <br />Date <br /> <br />J6-- <br />