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<br />CERTIFICATION OF COMPLIANCE <br />MINNESOTA WORKERS' COMPENSATION LAW <br /> <br />Minnesota Statute Section 176.182 requires every state and local licensing agency to withhold the <br />issuance or renewal of a license or permit to operate a business or engage in an activity in Minnesota until <br />the applicant presents acceptable evidence of compliance with the workers' compensation insurance <br />coverage requirement of Chapter 176. The information required is: the name ofthe insurance company, <br />the policy number, and dates of coverage or the permit to self-insUf"e. This information will be collected <br />by the licensing agency and retained in their files. <br /> <br />This information is required by law, and licenses and permits to operate a business may not be issued <br />or renewed if it is not provided andlor is falsely reported. Furthermore, if this information is not provided <br />or falsely stated, it may result in a $2,000 penalty assessed against the applicant by the Commissioner <br />of the Department of labor and Industry. <br /> <br />Insurance Company Name: <br /> <br />(NOT the insurance agent) <br /> <br />Policy Number: <br /> <br />Dates of Coverage: <br /> <br />to <br /> <br />(or) <br /> <br />I am not required to have workers' compensation liability coverage because: <br /> <br />o I have no employees <br /> <br />o I am self insured (include permit to self-insure) <br /> <br />o I have no employees who are covered by the workers' compensation law (these include: <br />Spouse, Parents, Children and certain farm employees) <br /> <br />.........***.*****..... <br /> <br />I certify that the information provided above is accurate and complete and that a valid workers' <br />compensation policy will be kept in effect at all times as required by law. <br /> <br />Name: <br /> <br />(last, first, middle) <br /> <br />Doing Business As: <br /> <br />(business name if different than your name) <br /> <br />Business Address: <br /> <br />City, State, Zip: <br /> <br />Phone: ( ) <br /> <br />Signature: <br /> <br />Date: <br />