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CERTIFICATE OF COMPLIANCE MINNESOTA WORKERS' COl\fPENSATIONLAW 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 ofMSS Chapter 176. The information 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 :fulsely 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 of the Department of Labor and Industry. Insurance Company Name: (NOT the insurance agent) .. ~r ~ /-/-Ob TO /)"3/'0' Policy Number: Dates of Coverage: (OR) I am not required to have workers' compensation liability coverage because: o I have no employees o o I am self-insured (include permit to self-insure) I have no employees who are covered by the workers' compensation law (these include: spouse, parents, children and certain farm employees) I certify that the information provided above is accurate and complete and that a valid workers' comp .on policy will be kept in effect at all tim as required by law. cdI. J( Ci~ Business Phone: ~ ! /- 1--05 Date Name: Name of Business: Business Address: ~1