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Sep-11-2002 02:lApA Prae-CITY OF OR� +A6224Ad616 T-018 P.006/006 F-9A6 <br /> r�oF oF wox�s� COMP'ENSATION YNSURANCE COV �'RACE � <br /> Nlinnesoca Statute Sadon iT6.182 rcquires every state and lacal l�xas�sig age�cy w witbhold <br /> the issuance or teoea►al of a licensc or permit w operat,e a busi�ess in Minaesota wrtil the <br /> � . $Pp�P�� �ble evideace of compliance aith t1�worbers' compensaaon iasucancc <br /> ' coverage requiremeat of Section 176.181, Subd. 2. The infornaation requirod �s: 'rht name of <br /> th�e�insurance company► the policy�awaber, and dates of coverage or the pennit ta self-ins�u�e. <br /> This informatian an71 be colleeced by thc lieensi�ageneY aad Put in their eono�any tile. Ic will <br /> t,e furnish�ed, upon rcqu�st, to the Depazwn�nt of L,abor aad Industry to cluck f,or compliaaece <br /> with Mfnnesota Statut�Sec. 176.I81� Subd. 2. <br /> Tbis information is requined by law, aad licenses an�d permits to operate a busi�ss may not be <br /> issuc8 or reaewed if it is not pmvlded and/or is falsely report�ed. Furthtrmore. if this <br /> information is not pr�vided andJor falsely reported, �t may resalt in a$1,000 penalty asscssed <br /> against thc applicant by t�e Commisaioner of the Depattmeut of i.abor aad Ipdusvy payabk to <br /> � the Special Compansation�nd. . <br /> Provide the lnfdrmation spxiSed abovc in tlie spaces provided, or cestify tl�e precise reason <br /> yowr business is exeluded Prom compliaAce with�iasuc�e coverage requir�ment�or workers' <br /> compensatio�. <br /> �uatica Campeny Name: <br /> ( T� thc insuraaac agent) � � <br /> Policy Number or Self-Insuramce Permit Number: <br /> Dates of Coverage: <br /> OR <br /> i am na,t required to havc workers' compensation liability coverage becaase: <br /> (�(j I have no employees covered by the law.. <br /> . . ( ) Other(SPxifY) , . � <br /> I HAVE�tF.AD AND UNDERSTAND MY RIGHTS AND OBLTGA7'IONS WITT�RE(�ARDS <br /> TO BUSYI+tF.SS LICBTISES� PERMTTS AND Wd�ERS' COMPENSATION COVERAGE, <br /> AND I CERTIFY THA'� THE INFO1tMATION PYtOVIDED IS TRUE AND CORREC'7'• <br /> tsitu�are> �> <br /> (�Y> l�Phooe 1Vombec) <br />