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� <br />STATE OF n�TNESOTA <br />Department of Human 5ervices <br />Department of Corrections <br />Divisians of Licensing <br />PRUOF G1F WORKER'S CUMPEN5ATION INSURANCE CQVERAGE <br />Under Minnesota Statutes, section 176.182, the Departrnent of Human Services (DHS) and the Departrnent <br />of Corrections (DOC) are prohibited from issuing ar renewing a license until the applicant presents <br />acceptable evidence of cornpliance with the wprker's compensation insurance requirement of section <br />176.181, subdivisian 2. <br />L7nder the Minnesota Government Data Practices Act, we musi advise you that: <br />• DHS or DOC may supply this infarmation to the Departrnent of Labor and Industry. <br />• Failure to supp�y this infarmatian may be a basis to deny the issuance of yaar license. <br />Please frll iti the foIIowing information and return this form aiong with your applic�tion to the <br />Depar�nen� of Human �ervices, Licensing Division. <br />� <br />Applicant's Naxne � J (Program Name) <br />���}- �.r,� GL� C�v�� �= I �I b <br />Prograrn Street Address <br />�� � �, �VI I� �� � � � <br />City State Zig Code <br />Worker's Compensation Coverage Information: <br />Complete Information Below Unless Exempt by the Department of Labor & Industry <br />Narne of Insurance Cornpany <br />VVVIV���CJ.�-I � I�Vf� <br />Worker's Compensation Insurance Policy Nunnber Pezmit ta Self-Insure <br />Ef%ctive Dates af Coverage Fram: �� b� ��1¢- To: U� �� 2�1 �,� <br />Month Day Year Month Day Year <br />THIS FORM MUST BE SIGNED .AND DATED <br />EVEN IF YOUR LICENSE DC1ES NQT REQUII2E PROOF OF WORKER'S COMPENSATION <br />� <br />�ignature Title Date ' <br />Far questions regarding Worker's Compensation requirements, contact the Minuesota Department of Labor <br />& Industry at (651) 297-4377 or 1-800-342-5354. <br />MS-2U64-ENG <br />�-QS <br />