2002-12-09 CC Packet - Laserfiche WebLink

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I- I , , I I I CERTIFICATE OF COMPLIANCE MINNESOTA WORKERS' COMPENSATION LAW Minnesota Statute, Section 176.182 requires every state and local licensing agency to withhold the issuance or renewal of a license or permit to operate a business or engage in an activity in Minnesota until the applicant presents acceptable evidence of compliance with the workers' compensation insurance coverage requirements of MSS Chapter 176. The infonnation required is: the name of the insurance company, the policy number, and dates of coverage, or the permit to self-insure. This information will be collected by the City and retained in the files. This information is required by law, and licenses and permits to operate a business may not be issued or renewed if it is not provided and/or is falsely reported. Furthermore, if this information is not provided or falsely stated, it may result in a $1,000 penalty assessed against the applicant by the Commissioner ofthe Dfpartment of Labor and Indu.stry. Insurance Company Name: (tlOT the insurance agent) '?>~ r\<. ( 'y , 4d""N.slrtl-lor~ Policy Number: iN c:. Z z. O'i 1:;,:5 "3311- 00 t l /0 J TO ~ Z /3 i /6 'I. I I ' ; Dates of Coverage: (OR) 1 am not required to have workers' compensation liability coverage because: o I have no employees o I am self-insured (include permit to self-insure) o I have no employees who are covered by the workers' compensation law (these include: spouse, parents, children and certain farm employees) 1 certifY that the information provided above is accurate and complete and that a valid workers' compensation policy will be kept in effect at all times as required by law. Name: I;..), { I , ~_ [First] ::rt /' O"M t:- [Middle] 73IHK [Last] Name of Business: ~~ {{ 'r I S I/D,....J ./' . J:J1JG. Business Address: _.10'1 'if - Cf.,w fir II Ii (( I2d C'Ady,),!!~ /YI,J [City] [State] ~~--..' 55tJJg [Zip] Business Phone: t,..5/-&S3- ~1ft~ p~ Signatur or;)/. I', () ?_ Date