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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 pennit 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 of MSS Chapter 176. The information required <br />is: the name of the insurance company, the policy number, and dates of coverage, or the pennit <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 andlor is fuIsely 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: q:"'z.,O~\6 ~W~ <br />(NOT the insurance agent) <br /> <br />Policy Number: <br /> <br />'01 'l. V~"Z- \ <br /> <br />Dates of Coverage: <br /> <br />1.-\\ )01. <br /> <br />TO "7- W 0-:' <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 />o <br /> <br />I am self-insured (include permit to self-insure) <br /> <br />o I have no employees who are covered by the workers' compensation law <br />(these include: spouse, parents, children and certain furm employees) <br /> <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: <br /> <br />.-r- <br />h()D <br />[First] <br /> <br />IV\'<'-'~'- <br /> <br />~~ <br />[Last] <br /> <br />tP'ul1.=- ~(J(W',s. <br /> <br />Name of Business: <br /> <br />[Middle] <br />\) <br />\'0 '5\"l\~ ':t:l\e.-.~ <br /> <br />Business Address: <br /> <br />\qC\.'i) <br /> <br />"",-",,;..::, <;h. <br /> <br />Business Phone: <br /> <br />4 \l'\ t~'L <br />Date <br /> <br />~,~ <br />[City] <br />lc:>'::,\ <br /> <br />\'(v'\~ <br />[State] <br />1::\ l.lp - (P(P 016 <br /> <br />SSD~~ <br />[Zip] <br /> <br />'fih~ <br />Signa <br />