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O^.> 00 OD 100'� CO VLL^T IIO}SL'C i►[C ID-010 pC J' 0101 I'' . 00 <br /> wow 1',114if Y4i r-i as <br /> j�p,fir <br /> nen A A� n.. r`t•a waij.w-ter' .' 11.74.4i <br /> 4 L".747A i L'JJ Ah m ULt ��r� .V Tv i A( E <br /> Minnesota Statute Section 176.182 requites every state and local`flcensing 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' competion insurance <br /> coverage requirement of Section 176.181, Subd. 2. The information required its 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, Sttbd. 2. <br /> This information is required by law, and licenses and permits to operate a buss may not be <br /> issued or renewed if it is not provided and/or is falsely reported. Furthencnore, if this <br /> information is not provided and/or falsely reported, it may result in a $1,000 petty 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 the spaces provided, or certify the,precise reason <br /> your business is excluded from compliance with the insurance coverage requirem ni for workers' <br /> compensation, <br /> \ <br /> Insurance Company Name: . <br /> (NOT the insurance agent) <br /> (12 Policy Number or Self-Insurance Permit Number: S 7 J- ? <br /> Hates 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 (SP `Y) ,T <br /> I HAVE READ AND UNDERSTAND MY RIGHTS AND OBLIGATIONS WI REGARDS <br /> TO BUSINESS LICENSES, PERMITS AND WORKERS' COMPENSATION'COVERAGE, <br /> AND I CERTIFY THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT. <br /> 7-9 <br /> Pug) <br /> C o.�� e � � 3 z S. S'3 6 <br /> (Company) �, (ewe triage Matted <br />