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<br />Certificate of Compliance <br />Minnesota Workers' Compensation Law <br /> <br />PRINT IN INK or TYPE. <br /> <br />Minnesota Statutes, Section 176.182 requires every state and local licensing agency to withhold the issuance or <br />renewal of a license or permit to operate a business or engage in any activity in Minnesota until the applicant <br />presents acceptable evidence of compliance with the workers' compensation insurance coverage requirement of <br />Minnesota Statutes, Chapter 176. The required workers' compensation insurance information is the name of the <br />insurance company, the policy number, and the dates of coverage, or the permit to self-insure. If the required <br />information is not provided or is falsely stated, it shall result in a $2,000 penalty assessed against the applicant by <br />the commissioner of the Department of Labor and Industry. <br /> <br />A valid workers' compensation polley must be kept in effect at all times by employers as required by law. <br /> <br />BUSINESS NAME (Individual name only if no company name used) LICENSE OR PERMIT NO (~applicable) <br /> <br />~DS LlQU jJ1lC <br /> <br />DBA (doing business as name) (if applicable) <br /> <br />- ''5 U rl <br /> <br />BUSINESS ADDRESS (PO Box must include street address) CITY STATE ZIP CODE <br /> <br />/I 3 ZOTH I/!. C8VflRJ/!!Lf JIJ. 5SO 38 <br />YOUR LICENSE OR CERTIFICATE WILL NOT BE ISSUED WITHOUT THE <br />FOLLOWING INFORMATION. You must complete number 1,2 or 3 below. <br />NUMBER 1 COMPLETE THIS PORTION IF YOU ARE INSURED: <br />INSURANCE COMPANY NAME (not the insurance agent) <br /> <br />WORKERS' COMPENSATION INSURANCE POLICY NO. <br /> <br />EFFECTIVE DATE <br /> <br />EXPIRATION DATE <br /> <br />NUMBER 2 COMPLETE THIS PORTION IF SELF-INSURED: <br /> <br />o I have attached a copy of the permit to self-insure. <br /> <br />NUMBER 3 COMPLETE THIS PORTION IF EXEMPT: <br />I am not required to have workers' compensation insurance coverage because: <br /> <br />M I have no employees. <br />o I have employees but they are not covered by the workers' compensation law. (See Minn. Stat. ~ 176.041 for a list of <br />excluded employees.) Explain why your employees are not covered: <br /> <br />o Other: <br /> <br />ALL APPLICANTS COMPLETE THIS PORTION: <br />I certify that the Information provided on this form Is accurate and complete. If I am signing on behalf of a businesa, I <br />certify that I am authorized to sign on behalf of the business. <br /> <br />ory) TITLE <br /> <br /> <br /> <br /> <br />Rsation policy is cancelled within the license or permit period, you muat notify the <br />or permit by resubmlttlng this form. <br />different forms, such as large print, Brollle or on a lape. To request, csII1-4lOO-342-li3S4 (DIAL-DLI) Voice or <br /> <br />~/ <br />