Laserfiche WebLink
<br />MINNESOTA WORKERS' COMPENSATION ASSIGNED RISK PLAN <br />APPLICATION FOR WORKERS' COMPENSATION INSURANCE <br /> <br />Send to: Minnesota Workers' Compensation Insurers Assn., Inc. <br />7701 France Avenue South, Suite 450 <br />Minneapolis, Minnesota 55435-5288 <br />(612) 897-1737 <br /> <br />QOVERAGE CANNOT BE BOUND BY ANY AGENT. <br />This application must be typed or printed and filed in duplicate with the Association. <br />See rules and procedures on back of application. <br /> <br />Enclose check payable to: MN Workers' Co nsation Assigned Risk Plan. Payment must be made by certified check, bank draft, <br />mone order finance check 0 a enc e Coverage will not be provided if.the correct payment or deposit premium does not <br />accompany t e app lcatlon, ectlon an ction IV are not fully completed; if the Declination requirement is not met; if the <br />application is not signed by applicant and agent; if there is a record of coverage in force in the Association file; or if it is found that <br />the employer applying for coverage owes money to the Assigned Risk Plan for previous coverage or has failed to comply with the <br />Audit conditions of any previous policy. . <br /> <br />~rage will become effective (1) 12:01 a.m. the day after the postmark date on the envelope containing the app'lication and deposit <br />premium or (2) 12:01 a.m. the day after receipt of the application and deposit premium if not postmarked or If made by personal <br />delivery or (3) 12:01 a.m. on any future date requested. . <br /> <br />The undersigned employer hereby applies for workers' compensation insurance in Minnesota and expressly represents that such <br />insurance is sought in good faith. <br /> <br />COVERAGE IS DESIRED* <br /> <br />Effective <br /> <br />Dale <br /> <br /> <br />It-ztV'f <br />(Stale) <br /> <br />(Phone) <br /> <br />(Slmel) <br /> <br />(City) <br /> <br />(State) <br /> <br />(Zip) <br />(Zip) <br /> <br />(Stale) <br /> <br />(Zip) <br /> <br />(Slmel) (City) <br />II. BUSINESS INFORMATION <br /> <br />::i) legal Status: 0 Sole Proprietor 0 Partnership 't!-Corporation <br />. 0 Closely Held Corporation 0 Professional Association 0 Trust <br />o Board of Directors, Corporate Officers, General Partners, Sole Proprietors <br />~ tiame Tille . () Duties <br /> <br />r:e~ ~MI\ 00 P~f,)M- &5Iw~;: cL <br /> <br />o limited liability Co. <br />o Other <br /> <br />o Non-Profit Organization <br /> <br />SSN <br /> <br />Pe<cent m Approxlma1e <br />0wnecsIlip AnooaI Salary <br />IrnJ <br />. <br /> <br />(fC{ - 7{).-O 770 <br /> <br />~__Banking Institution lA).LU 5 ~ <br /> <br />~unt No. <br /> <br />III. INSURANCE RECORD <br /> <br />~ Has there been previous workers' compensation insurance coverage in Minnesota? 0 Yes ~NO <br />. Explain: . <br />@) Has there been a name change or change in ownership during the past three years? 0 Yes ~ No <br />Did you purchase the business, or any part of it, from someone else? 0 Yes ~o <br />If you answered "yes" to either of the above, give previous name, ownership and date of change/purchase. <br /> <br />~ Minnesota Workers' Compensation Insurance Record - Three Previous Years: <br />v State Insurance Company Policy Number <br /> <br />= Period <br />To <br /> <br />Premiums Paid <br /> <br />rJ~ <br />