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MINNESOTA DEPARTMENT.OF:PUBLIC SAFETY oFFICE.usE.oNLY <br /> DRIVER AND:VEHICLE SERVICES <br /> 445 Minnesota Street, Suite 186, St..Paul,MN 55101-5186 DEALER NUMBER. <br /> PHONE;651-296-2977 DATE RECEIVED: <br /> FAX 651-297-1480 INITIALS: <br /> EMAIL:.DealerQuestion@mndriveinfo:org . <br /> Certification of Compliance with'Minnesota Worker's Compensation Law <br /> This certification must accompany an application for a Minnesota motor vehicle dealer's license <br /> Minnesota Statutes,section 176:182 requires every state and local licensing agency to withhold the issuance or renewal of <br /> a license or permit to operate a business or engage in an activity in Minnesota until theapplicant certifies that they are in <br /> compliance with the workers'compensation coverage requirements outlined in section:176. <br /> pailiire tc.provide the following information or reporting.false information will result in the denial your'license <br /> application.'Providing false informationmay result in a$2,000 penalty. <br /> INSURANCE INFORMATION <br /> � C1n <br /> Name of insurance Company(not agent) <br /> Policy Number. ! <br /> Dates of Coverage: / ! / to ,/ <br /> EXEMPTION <br /> I am not requiired.to have workers'compensation liability coverage because(please.che6k one):. <br /> Q I have no employees <br /> Q I am self-insured(attach permit to self insure) <br /> Q I have no employees-who are covered by the.workers' compensation law(these include: spouse,parents,children) <br /> I certify that the information provided above is accurate and complete and that a valid workers'compensation policy will <br /> be kept in effect at all times as required by law. <br /> Dealership Name: <br /> LLC___1 <br /> Street <br /> city_ State IV Zi Phone: <br /> P N/I O <br /> .. <br /> Print name of Signer: . m A 1.1 It 1 �QN e IZ <br /> X DATE: 7l� <br /> (SigigkMie of wrier/Officer) <br /> PS2420-01 <br />