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PROOF OF WORKERS' COMPENSATION INSURANCE COVERAGE <br /> Minnesota Statute Section 176.182 requires every state and local licensing agency to withhold <br /> the issuance or renewal of a license or permit to operate a business in Minnesota until the <br /> applicant presents acceptable evidence of compliance with the workers' compensation insurance <br /> coverage requirement of Section 176.181, Subd. 2. The information required is: The name of <br /> the insurance company, the policy number, and dates of coverage or the permit to self-insure. <br /> This information will be collected by the licensing agency and put in their company file. It will <br /> be furnished, upon request, to the Department of Labor and Industry to check for compliance <br /> with Minnesota Statute Sec. 176.181, Subd. 2. <br /> This information is required by law, and licenses and permits to operate a business may not be <br /> issued or renewed if it is not provided and/or is falsely reported. Furthermore, if this <br /> information is not provided and/or falsely reported, it may result in a $1,000 penalty assessed <br /> against the applicant by the Commissioner of the Department of Labor and Industry payable to <br /> the Special Compensation Fund. <br /> Provide the information specified above in tYie spaces provided, or certify the precise reason <br /> your business is excluded from compliance with the insurance coverage requirement for workers' <br /> compensation. <br /> Insurance Company Name: <br /> (NOT the insurance agent) <br /> Policy Number or Self-Insurance Permit Number: <br /> Dates of Coverage: <br /> OR <br /> I am not required to have workers' compensation liability coverage because: <br /> ,(��I have no employees covered by the law. <br /> ( ) Other (Specify) <br /> I HAVE READ AND UNDERSTAND MY RIGHTS AND OBLIGATIONS WITH REGARDS <br /> TO BUSINESS LICENSES, PERNIITS AND WORKERS' COMPENSATION COVERAGE, <br /> AND I CERTIFY TH� T ,INFORMATION PROVIDED IS TRUE AND CORRECT. <br /> � � <br /> �_ � �� d v <br /> (Signatu _i � ? � (Date) <br /> C�� � �/ �'�Tl�� --�03� _G��r�� <br /> ( mpany) (Business Phone Number) <br /> C�r 2 �f�`,L 3 G s-s— `�p-'v-,� <br />