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V. DECUNATlON STATEMENT (Coverage will not be provided if this section is not completed) In order to obtain workers' compensation coverage through the Minnesota Workers' Compensation Assigned Risk Plan, you must first have been declined coverage - by an insurance company licensed to write workers' compensation in the State of Minnesota - within 60 days of the requested coverage effective date. I (we) have applied to the insurance company named below and have been refused Workers' Compensation Insurance. Note: If you are currently insured, the company listed must be your present insurance company. The representative named must be a full time, salaried employee of the company, . Name 01 Insurance Company Full Name oIlJnde1wrilef SoIicilalion Dale ~VI. ELECTIONS AVAILABLE UNDER THE LAW (Coverage will not be provided for exclu suess they are listed in this section) READ CAREFULLY Minnesota Workers' Compensation law (MS 176) excluoo certain persons such as sole proprietors, partners, certain executive officers of family farm or closely held corporations, and their spouses, parents and children (regardless of age). An election may be made to provide coverage for those excluded by completing the information below. The following named individuals who are subject to the election of coverage are to be covered by this policy. List only the individuals who elect coverage. Name of Person to be insured Trtle or Relationship Duties Estimated Remuneration or Draw - included in Section IV ~as the estimated remuneration, subject to minimums and maximums, of the above named individuals been included in 51 Section IV? 0 Yes 0 No QVII. STATEMENTS AND AGREEMENTS (Coverage will not be provided if this section is not completed) -1 (we) have read this application for the granting of coverage to employers unable to secure it for themselves arid subscribe to the Minnesota Workers' Compensation Assigned Risk Plan in its entirety, and hereby declare myself (ourselves) bound by its provisions, and by all provisions of the Standard Workers' Compensation and Employers' Liability Policy. I (we) will comply with all reasonable safety recommendations that the servicing contractor makes with a view to reducing the hazards to which my (our) employees are exposed. I (we) hereby agree to pay promptly all premiums when due with the understanding that failure to do so shall constitute authority for the Servicing (Insurance) Contractor to cancel- coverage. - I (we) understand the law regarding the election of coverage for Workers' Compensation Insurance. I (we) understand excluded individuals will not be covered by this policy unless named under Section VI. I (we) hereby certify the above statements are true and correct, and there are no outstanding premiums due the Plan. I (we) hereby designate o..s<.6<'::\.c-~~ D ~s.~-o. r-<...C Q~ )':~. Name Agent 0< Agency as agent of record for this insurance. I (we) understand that the agent is not acting as an agent of any company for the purpose 0 this insurance and has no authority to bind such insurance. I (we) also understand that the agent is not an agent of the Assigned Risk Plan for purposes of state law. €4J.4Y~ if-Ib-O? Dale __.___.11.'_ _~___A_M__'