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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 compliance <br />with the workers' compensation insurance coverage requirement of Minnesota Statutes, Chapter 176. If the required <br />information is not provided or is falsely stated, it shall result in a $2,000 penalty assessed against the applicant by the <br />commTssioner 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) BUSINESS TELEPHONE NO. <br />FAX TELEPHONE NO. <br />I 612-366-0163 <br />NA <br />BUSINESS NAME (Use the person(s) name If business structure is sole proprietor or partnership (Le., John Doe, or John Doe and <br />Jane Dae), otherwise it is the legal name of the business entity.) <br />Voyageur Service Centers Inc. <br />DBA ('doing business ae or also known as an assumed name) (if applicable) <br />O'Sullivan Holiday <br />BUSINESS ADDRESS (must be physical street address, no PO boxes) <br />CITY STATE ZIP CODE <br />2420 Shadywood Road <br />Navarre MN SS392 <br />COUNTY I <br />E-MAIL ADRESS <br />Hennepin <br />johnos@tcinternet.net <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 />NAIC Number. <br />'ftr <br />POLICY NO. <br />EFFECTIVE DATE <br />EXPIRATION DATE <br />f f 36 <br />/f 120 e,4 <br />1 // // /2 0 17 <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 65..284.5032 or <br />1400.342-5354. <br />e1have no employees. (See Minn. Stat. § 175.011, subd. 9 for the definition of an employee.) <br />I am self-insured for workers' compensation (include a copy of authorization to self -insure from the Minnesota Department of <br />Commerce). <br />1 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 SIGNATURE (mandatory) TITLE DATE <br />NOTE: YjWnust notify us if there is any cftange to your Workers' Compensation Insurance Informatlon or Employee Status Change by resubmitting <br />this form. This material can be made available in different forms, such as large print, Braille or on a tape. http-lbe w.dii.mn.Qov/WC/PDELmnllc pdf <br />LIC 04 (9/12) <br />Page 7 <br />