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MINNESOTA WORKERS' COYPENSATION A$S1�#NED RISK PLAN <br />APPLICATION FOR WORKERS' COMP�NSATION IHSURANCE <br />COVERAGE IS DESIRED` �d to: Minnesota VNorkers' CompsnsaUon Insurers Assn., inc. <br />! 7701 Franc:e Av�enue Soulh� Suite 450 <br />� � � 6 2) 7-1g737�� ��5� <br />VERAtiB CANNOT 6E B01Ji� BY ANV AOBNT. <br />This appl ti�on must be iyped or prir�ted and tiled in du�Ncate with tl�e Associatlan. <br />See rules and procedures on badc of applicatior�. <br />Ehdose check payable to: MN Workers_' �Co p�ensation R'isk Plan.Paym ent m be made by oertifled chedc benk dtait <br />mone�► orcier. finance d�edc �iF�'-cfiedd Ca+�erage wA�t be provtder i�•tl�e corr� payrt�t or epo�si�prem ui� m cf�o'e� <br />accompany ap ,�e ion 1 and�3ectian lY are not fulty completed; i1 the Dedinatian uirement i� not met; if the <br />application is not s ned by applicant and agent; if thete is a recond of �oMerage in foroe in the Asso�a�on file; ar if it is �und that <br />the emp�yer app� y�ng for c�verage owes money to th� Assig�ed Rlsk Ptan for previous cflverage or has failect to oomply w1th the <br />udit cond�ions of any pre�vious policy. . <br />�erage wUi become et�ecti�e 1)12:01 am. the after ihe ric date on the ernrelope ooniatn� thea �cation ertid depas'rt <br />( c�ypostma pp1ad <br />premium or (2)12:01 a.m. the day after receipt of ti�e applica o�i n and deposit premium ff not postma�ced o� if made by personal <br />delivery or (3)12:01 a.m. on arry future date requested. <br />The undersigned employer hereby appNes for workers' compensaUon insurance in Minnesota and expressly �epresents that such <br />insuranc;e is sought in good faitli. <br />� <br />� <br />1. GENERAL INFORMATION <br />wiil not bepro� ided if this section ts <br />GQ,.i v-�e SP,rv r cc,s �.1.► � ni <br />� . . . . - • -• - - - - � <br />— a� �dd�esa (Stieeq caer) tsta+e) (zv1 <br />s. <br />�oa,� �w,� �, cs,�� c«�» cs�� «> <br />u. BUSINESS INFORMATION <br />� L,egal Status: ❑ Sole Proprietor ❑ Partnership '�orporatlon ❑ Umited Vability Co. <br />� ❑ Closely Held Corporation ❑ Professional Association ❑ Trust ❑ Other <br />� Board vf Di�dors, Corporate Officers� General Partners� Sole Proprietors <br />wrne TNs , ou6m ssN <br />r- f i n_ __r � L- ���"��: <br />�sar,wng �nst;h,tion <br />IU. INSURANCE RECORD <br />❑ Non-Profit Organizatlon <br />�.�cen a �ypma�s <br />o.�w�+�y N..�r s+vy <br />No. . <br />� Has the�e been pre�vious workers' compensa�on Insurance cove(age in Minnesota? ❑ Yes �No <br />�� Explain: <br />2.� Has there been a name change or change in ownership during the past tfiree years? �❑ Yes � No <br />Did you purchase the business, or arry part of it, from someone else? ❑ Yes �(,No <br />ff you answered `yes" to e'rther of the above, give p�evious name, ownership and date of change/purchase. <br />��IinnesotaWorkers' ��y n insurance R�-�Three P�eviousYears: �� P�� <br />(� � <br />