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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 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 infonnation is required by law, and licenses and permits to operate a business may not be issued or renewed if it is not provided andlor is falsely reported. Furthermore, if this infonnation is not provided or falsely stated, it may resuh 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) CL(J~ Dates of Coverage: ~F~- 37J2#ky TO 5/at'/.d;S- (OR) Policy Number: I am not required to have workers' compensation liability coverage because: $- 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) I certify that the information provided above is accurate and complete and that a valid workers' compensation policy wiJJ be kept in effect at aJJ times as required by Jaw. Name: ~ Business Phone: JJ..a~MV~ [Middle] ro~ />1~ /8'0/ m~ 41. &~,~ [City] ./ [State) & S I ~ I..f??-I- ~7 '-ILl S-/1Jfo,hr C/J~ bate Signature (First) ~ [Last] Name of Business: Business Address: 55"038 [Zip]