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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 $2,000 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 <br />BUSINESS TELEPHONE NO. I FAXTELEPHONE NO. <br />952-4714MM 1 NA <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 />Rick Wood — Wood Enterprises Inc. <br />DBA ("doing business as" or also known as an assumed name) (if applicable) <br />Navarre <br />BUSINESS ADDRESS (must be physical street address, no PO bones) CITY STATE ZIP CODE <br />3421 Shoreline Drive I Navarre MN 55392 <br />COUNTY E-MAIL ADRESS <br />Hennepin navarmliquors@yahoo.com <br />YOUR LICENSE OR CERTIFICATE WILL. NOT BE ISSUED WITHOUT THE FOLLOWING <br />INFORMATION. You must complete number s or 2 below. <br />NUMBER 1— Workers' compensation insurance policy information <br />INSURANCE COMPANY NAME (not the insurance agent) NAIC Number. <br />POLICY NO. EFFE VE D TE EXPIRATION DATE <br />1�CV4107 ��-�I� f �t or7 IzAi/-z&'�/ 17 <br />NUMBER 2 — Reason for exemption from workers' cbmpeion insuranch / <br />If you have questions regarding the need to obtain workers' compensation coverage, including exemptions, contact 651.284.5032 or <br />14K)0-342-5354. <br />H <br />I have 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 self -insure from the Minnesota Department of <br />Commerce). <br />❑ I have employees but they are not covered by the workers' compensation law. (see Minn. Stat. § 175.041 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 />APPLICANA RE to ) TITLE: DATE <br />G . oL <br />NOTE: You must notify us if there is an change to your workers' Compensation insurance Information or Employee Chan by resubmitting <br />this form. This material can be made g6aflable in different forms, such as large print, Braille or on a tape. htto: ww.d11.M&.jz0v1WbPQF/MnI1004.DdF <br />LIC 04 (9/12) <br />paw <br />