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Oct-O6-2000 �D:18�m From-CITY OP ORONO +95224�4616 T-761 P.004/004 F-'33 <br /> PROO�' OF 'WOR.�RS' C4MPENSATI�N Il`S�3R�.'�CE COVERAG� <br /> Min,nesota Statutc Section 1.76.182 requires every state a.nd local licensing agency to withhotd <br /> the issuance or renswal of a Iicense or permit to operate a business in 3�Sin�esota until the <br /> applicant presents acceptable evidence af complianee wich t�ie wor�ters' compensarion in.surance <br /> � coverage requirement af Sectian 176.181, Subd. 2, 'T'he �nformation requued is; The name of <br /> the 's.nsurance company, the policy numb�r, and datas of coverage or tkie pe�mit to sclf-insure. <br /> This information will be eollected by che liccnsing agency and put in their couipany file. It r;vill <br /> be furni;hcd, upon request, to the Department of Y.,abor and Indusuy w check for cornpliance <br /> with Minnesota Statute Sec. 176.181, Subd. 2. <br /> This informatian is requued by law, and ticenses and permits to o�eratc a business may not be <br /> issued or renewed if it is not Qrovided andlor is falsely reported. �rthcrmore, if this <br /> information is not provided and/or falsely roported, it ma� resul[ in a $1,000 penalty assessed <br /> against thc applicant by the Commissioner af the Deparcment of Labor and Yndusuy payable to <br /> the Special Compensation Pund. <br /> Provide the infornsation specified above in die spaces provided, �r certify the precise reason <br /> yotu business is excluded fiom complia�ce�vith the it�surance coverage requirement for warkexs' <br /> compensation. <br /> 3rLsurance Comgany Nam�; <br /> (1VOT the insurance agent; <br /> Policy Number or Self-Insurance l�ermit Number: <br /> Dates of Covenge: ` <br /> � O�t <br /> I am noc reqL'u•ed co have Warkers' compensation liability c�verage because: <br /> (� � have na employees covcred by the law. <br /> ( ) Och..-r (Speci�y) <br /> I�TAVE R�AD AND'(IND�STAND MY RTCrHTS AND OB�IQATIONS WiTH REGAR�S <br /> Td BU'SINESS I.ICENS�S, PERMITS AIvD �VORKERS' COVLPENSATYON C�VERACsB, <br /> �1p Y Gp,'FtTIFy THAT THE INF TI�N PROVIDED IS "I'RUE ANn CORRECT. <br /> (� � j�1 �6 " �� <br /> ma�, <br /> csigaamrc) ' <br /> /�}�^l s i!' e�� �1�,�-,1�►�-. �76 3 -- 5�0 - 55�� <br /> ` ' (Busiaess Pharx Numbc�) <br /> (CompaaY) <br />