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V. DECLINATION STATEMENT (coveragewill not be provided if this section is notcompleted) In orderto obtain workers' compensation �pV@fg� through the Minnesota Workers' Compensation ASSigI'19d Risk Plan, you must first have been dedined coverage -by an insurance company IiCe�lsed to write W01'k81�3' COmpenS8ti0n in the State of Minnesota — within 60 days of the requested CoVerage effedive date. have applied to thehSUranCe company named below and have been refused WorkerS' E� Nrne d rruianos comp.ry .. .. wr r�,�e a tMa�w�x isation insurance. representative named must ��--�.�--� �Vi. ELECTIONSAVAILABLEUNDERTHELAW (Coverage wi11 not be provided for exd nd�rfdue�s , they are listed in this section) AEAD. CAREFULLY Minnesota Workers' Compensation (aW (MS 176) eDCd ' 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 eledion may be made toprO�Vid6 coverage for those6�cdUd6d by completing the information below. The following named who eled coverage. Name of Perso to be insured individuals who are subject to the elBCtion of covemge are to be covered by this policy. List only the indiivais TiUe or Relationship Duties Estimated Remuneration or DfdW - included in S8Cti0n IV �as the estimated remuneration, subject to minimums and maximums, of the above named individuals been included in �ction N? 0 #l�� ❑ x0 QVii. STATEMENTS AND AGREEMENTS (Coveregewill not be prodded if thissection is not completed) -i (we) have read this application for the granting �of coverage to employers unable to secure it for themselves and subscribe to the Minnesota WOrk9rS' Compensatlon ASSighBdRisk PI�11 inits entirety, and hereby��@ 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 Servidng oonVactor makes with av�inr to reducing the hazards towhich my (our) employees are exposed. I(we) hereby agree to pay promptly all premiums when due with the understanding that fallure to do so shall constitute autllorliyfor theSeNiCing (Insurance) Contractor toC8rlCeF coverage. I(we) understand the law regardii the 818Ction of CoVerdge for Workers' Compensation insurance. I(we) understand �CdUd@d indiiiduafs Will not be coveredby this policy unless named under Section VI. I(we) hereby oertify the above statements are true and correct, and there are nooutstanding premiums due the Plan. I(we) hereby designate C��:.� �� `�...s,�-c�. -.� Q..� �«� . as agent of �BCOrd for this insurance. I(we) understand that the agent is not acting as an agAnt of any Company for the purpose o� 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. � �a� ,.. . , .. ..._...,--�---•----, �_ / b --p'�