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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 of MSS 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 fulsely stated, it may resuh in a $] ,000 penalty assessed against <br />the applicant by the Commissioner of the Department of Labor and Industry. <br />rC' ~ <br />Insurance Company Name: -r~O~\/\ ~<;W~ <br />(NOT the insurance agent) <br /> <br />Dates of Coverage: <br /> <br />'0-'1.. ~~1-\ <br />1..[ \ 101- TO '1-1~ O~ <br />(OR) <br /> <br />Policy Number: <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 />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 />~ <br />hOD <br />[First] <br /> <br />(V\. 'G\-\->\-1l; '- <br /> <br />~~ <br />[Last] <br /> <br />~~ ~PMs~ <br /> <br />Name of Business: <br /> <br />[Middle] <br />l) <br />'\.0 '5i'i.\~ :t:'l\C.- _ ~ <br /> <br />Business Address: <br /> <br />'''''YO ""'-oA-.~ <;"1. <br /> <br />~\'v<.AJ'~ \ '(v'\\j(J <br />(City] (State] <br />l,p'So\ '=\1Jp -(P(" oB <br /> <br />S~~~ <br /> <br />SSD~1S <br />(Zip] <br /> <br />Business Phone: <br /> <br />4 \l'\ t~<- <br />Date <br />