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Certificate of Compliance <br />Minnesota Workers' Compensation Law <br />PRINT IN INK or TYPE. <br />Minnesota Statutes, Section 176.182 requires every state and local licensing agency to withhold the issuance or renewal <br />of a license or permit to operate a business in Minnesota until the applicant presents acceptable evidence of <br />compliance with the workers' compensation insurance coverage requirement of Minnesota Statutes, Chapter 176. If <br />the required information is not provided or is falsely stated, it shall result in a $2,004 penalty assessed against the <br />applicant by the commissioner of the Department of Labor and Industry. <br />A valid workers' compensation policy must be kept in effect at all times by employers as required by law. <br />LICENSE or CERTIFICATE NO (if applicable) <br />BUSINESS TELEPHONE NO. I FAX TELEPHONE NO. <br />952-473-1909 1 952-249-4616 <br />BUSINESS NAME (Use the person(s) name if business structure Is sole proprietor or partnership (i.e., John Doe, or John Doe and <br />Jane Doe), otherwise it is the legal name of the business entity.) <br />City of Orono <br />DBA ("doing business as" or also known as an assumed name) (if applicable) <br />Orono Public Golf Course <br />BUSINESS ADDRESS (must be physical street address, no PO boxes) CITY STATE ZIP CODE <br />265 Orono Orchard Road 5 I Wayzata MN 55391 <br />COUNTYj E-MAIL ADRES5 <br />Hennepin I` <br />YOUR LICENSE OR CERTIFICATE WILL NOT BE ISSUED WITHOUT THE FOLLOWING <br />INFORMATION. You must complete number 1 or 2 below. <br />NUMBER 1— Workers' compensation insurance policy information <br />INSURANCE COMPANY NAME (not the insurance agent) <br />ke , <br />POLICY NO. <br />Z_to <br />EFFECTIVE DATE <br />NAIC Number. <br />EXPIRATION DATE <br />NUMBER 2 — Reason for exemption from workers' compensation insurance <br />if you have questions regarding the need to obtain workers' compensation coverage, Including exemptions, contact 651.284.5032 or <br />1800-342-5354. <br />B1have no employees. (See Minn. Stat. § 176.011, subd. 9 for the definition of an employee.) <br />I am self-insured for workers' compensation (include a copy of authorization to seflnsure from the Minnesota Department of <br />Commerce). <br />® I have employees but they are not covered by the workers' compensation law. (See Minn. Stat. § 176.041 for a list of excluded <br />employees.) Explain why your employees are not covered: <br />❑ Other: <br />I certify that the information provided on this form is accurate and complete. If I am signing on behalf of a business, I certify that I <br />am authorized to sign on behalf of the business. <br />APPLICANT SIGN AT E m awry) TITLE DATE <br />19C.V) SQ ff —A" -I,6 <br />NOTE: Yhu must notify us Ifth#A1 any change to your workers' Compensation Insurance Information 6r 15rnployee Status Change by resubmitting <br />this form. This material can Wmade available in different forms, such as large print, Braille or on a tape. htt .Uwww.dn.mn.xoylwCIPDF/mnuc0a odF <br />LIC 04 (9/12) <br />Page 7 <br />