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Certificate of Compliance Minnesota Workers' Compensation Law PRINT IN INK or TYPE. ires every state and local licensing agency to withhold the issuance or Minnesota Statutes, Section 176.182 requ renewal of a license or permit to operate a business or engage in any activity in Minnesota until the applicant presents acceptable evidence of compliance with the workers' compensation insurance coverage requirement of Minnesota Statutes, Chapter 176. The required workers' compensation insurance information is the name of the insurance company, the policy number, and the dates of coverage, or the permit to self -insure. If the required o information is not provided or is falsely stated, it shall result in a $2,000 penalty assessed against the applicant by the commissloner of the Department of Labor and Industry. A valid workers' compensation policy must be kept in effect at all times by employers as required by law. E (Individual name only if no company name v d LC-e. 5 )BA (doing business as name) (If applicable) BUSINESS ADDRESS (PO Box must include street address) o -r tn_C— CITY SE OR PERMIT NO (if applicable) iD ILI YOUR LICENSE OR CERTIFICATE WILL NOT BE ISSUED WITHOUT THE FOLLOWING INFORMATION. You must complete number 1, 2 or 3 below. NUMBER 1 COMPLETE THIS PORTION IF YOU ARE INSURED: INSURANCE COMPANY NAME (not the insuranc� agent) SATION INSURANCE POL CY O EFFECTIVE DATE EXPIRATION DATE NUMBER 2 COMPLETE THIS PORTION IF SELF -INSURED: �] I have attached a copy of the permit to self -insure. NUMBER 3 COMPLETE THIS PORTION IF EXEMPT: I am not required to have workers' compensation insurance coverage because: g%ve no employees. ve employees but they are not covered by the workers' compensation law excluded employees ) Explain why your employees are not covered: ❑ Other: (See Minn Stat. § 176..041 for a list of ALL APPLICANTS COMPLETE THIS PORTION: I certify that the information provided on this form is accurate and complete. If I am signing on behalf of a business, I certify that I am authorized to sign on behalf of the business. APPLICANT SIGNATURE (mandatory) TITLE DATE 0 {,�� j- Z� NOTE: If your Workers' Compensation policy is cancelled within the license or permit period, you must notify the agency who issued the license or permit by resubmitting this form. This material can be made available In different forms, such as large print, Braille or on a tape, To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 2974198. MN LIC 04 (11108)