2004-05-26 WS & CC Meeting - Laserfiche WebLink

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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 insntance 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 infonnaUon 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. Fwtbermore, if this infonnaUon 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) Cff~ ~F~- 37P-t7/& Y TO ~t:7.4;~ (OR) Policy Number: Dates of Coverage: .. _---"'--~~ ~_~".._._.__.._______ __ ._m__ ~.._---_.'._.- I I am not required to have worlrers' 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) 'CIte and complete and that a valid ect at all times as required by law. Name: JJ~~ [Middle] ro~ f)1~ /8l)/ m~ Q. &~, ;11--h [City] ./ [State] t, S I ~ if?"/ - &>7 LfLj S:/~h,/c;Y CfiJ ~ Date Signature [First] ~ [Last] Name of Business: Business Address: 5S-038 [Zip] Business Phone: 1_____ _ _ _ _