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Certificate of Compliance Minnesota Workers' Compensation Law PRINT IN INK or TYPE. Minnesota Statutes, 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 iany activity n 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 information is not provided or is falsely stated, it shall result in a $2,000 penalty assessed against the applicant by the commissioner 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. BUSINESS DBA (doing ME (Individual name only if no�company name used) ( G A-,,JS-U r�e,-Y J t,C_e. 5 siness as name) (if applicable) LICENSE OR PERMIT NO (if applicable) CITY � BUSINESS ADDRESS (PO Box must include street address) "" �Ili S-S:lI YOUR LICENSE OR CERTIFICATE WILL NOT BSUED WITHOUT 3T THE FOLLOWING INFORMATION. You must c pe a NUMBER 1 COMPLETE THIS PORTION IF YOU ARE INSURED: INSURANCE COMPANY NAME (not the insuranc agent) C wnRl<FRS' COMPENSATION 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: no employees, g�have ave employees but they are why your employees a enot covered by the ery' compenscovered: ation law. (see Minn 5tat. § 176.041 for a list of excluded employe ) Explain ❑ Other: 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, certify that I am authorized to sign on behalf of the business. APPLICANT SIGNATURE (mandatory) TITLE DATE Z O L t� 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 requesl, call 1.800-342.5354 (DIAL•DLI) Voice or TDD (651) 297.4196. MN LIC 04 (11/08)