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<br />07/06/2004 03:08 <br /> <br />6514848572 <br /> <br />ALL COUNTY AGENCY <br /> <br />PAGE 02/04 <br /> <br />"- <br />MINNESOTA WORKERS' COMPENSATION ASSIGNED RISK PLAN <br />APPLICATION FOR WORKERS' COMPENSATION INSURANCE <br /> <br />Send to: Minnesota Workers' Compensation Insurers Assn., Inc. <br />n01 France Avenue South, Suite 450 <br />Minneapolis. Minnesota 55435-3200 <br />(9521 897-1737 <br /> <br />COVERAGE IS DeSIRED" <br />EfleClive () 1-t)') -~ I{ <br />Dale <br /> <br />COVERAGE CANNOT BE BOUND BY ANY AGENT. <br />SEE RUU:S AND PROCEDURES ON LAST PAGE <br />Enclose check payable to: MN Workers' Compensation Assigned Risk Plan. Payment m.um be made by certified check b,mk draft <br />monev order. finance check or aQency check. Coverage will not be provided if the correct payment or deposit premIum does nol <br />accqmpany. the application. if Section I and Section IV are not fully completed; if the Declination requirement is not met; if the <br />apphcation IS not signed by applicant and agent, II there is a record of coverage in force in the Association file; or If it is found that <br />the employer applying for coverage owes money to the Assigned Risk Plan for previous coverage or has failed to comply with the <br />audit conditions ot any previous policy. <br />"Coverage will beoome effective (1) 12:01 a.m. the day after the postmark date on the envelope containing the application and deposit <br />premium or (2) 12:01 a.m. the clay after receipt of the application and deposlt premium if not POstmarked or II made by personal <br />delivery or (3) 12:01 a.m. on any future date requested. . <br />The Undersigned employer hereby applies for workers' compensation insurance 10 Minnesota and expressly represents that such <br />insurance is sought In good faith. <br /> <br />C !.fTI; t< <br /> <br />I. GeNERAL INFORMATION <br />" '!pt be provided if this sectfon is not oompleted) <br />J.,c- . <br />2b -.r-~~3"""/ ~ 7:1> <br />UnltmC:IIll>pl Cod6. '0 gl$ll1 Nllmba~ <br /> <br />MllI Ing Addrl!lU (1i'HtI <br />4. L1r ../ ~~ -J1 <br />Prlndp.l~'lcn _ <br />5. ...-, ~~--e <br />PByI'l:llI Olftca A~ <br />6. r:;.{_~ <br />OthAr~~l.1:dtIotl <br /> <br /> <br />~ a <br />IZI.J <br /> <br />lPI>""'J <br /> <br />(SlrMt} <br />/Slreet) <br /> <br />I""" <br /> <br />(Sl'\ItIJ) <br /> <br />IZI.) <br /><<<..I <br /> <br />iCily) <br /> <br />1_, <br /> <br />(stre",) (CIM <br />II. BUSINESS INFORMATION <br /> <br />(Slate) <br /> <br />(ZIp) <br /> <br />1. Legal Status: 0 SoJe Proprletor 0 Partnership 0 Corporation ~mited liability Co. <br />o Closely Held Corporation 0 Professional Association 0 Trust 0 Other <br />2. Board of Directors, Corporate Officers. General Partners, Sole Proprietors <br />NAIl"II naB ~U119ll <br /> <br />o Non-Profit Organization <br /> <br />.. <br /> <br />eM!.. <br />~ <br /> <br />&-t.r-- <br /> <br />1) f3C<Ef'IIt..JEe.. <br />~ <br />(/ <br /> <br />(JtfE5 <br />i/FJ <br /> <br />SON <br /> <br />.......... <br />Ownerahlp <br />~~ <br /> <br />A........... . <br />/lnIwtI1 ~hr'ary <br />? <br />;> <br />;> <br /> <br />;:> <br />. <br /> <br />'s;:--;;:;~ <br /> <br />3a. Banking Institution <br /> <br />M~.IfM. <br /> <br />3b. Acoount No. <br /> <br />.;2$.... <br />, ,;;I.$:.- <br />8'9- 794/- .:l.. <br /> <br />Ill. INSURANCE RECORD <br /> <br />1. Has there been previous workers' compensation insurance coverage in Minnesota? 0 Yes I;&,No <br />Explain: <br />2. Has there been a name change or change in ownership during the past three years? 0 Yes fl1 No <br />Did. you purchase the business or any part of it, from someone else? . 0 Yes ~o <br />If yOu answered "yes" to either of the above, give previous name. ownership and date 01 change/purchase. <br /> <br />...:~' <br />), <br /> <br />3. Minnesota Workers' Compensation Insurance Record _ Thrse Previous Years: <br />SftIhI If"lSllIDIIDA C:omptny PDllcy NUfIltrtlr <br /> <br />-/JO P/StJ.i.;1tUt1t!" <br /> <br />f'oIttoI Perbd <br />Frol'Tl TQ <br /> <br />P~III'TlI:Pllid <br /> <br />IJIJ4 <br />