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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 />commissioner of the Department of Labor and Industry. <br />A valid workers' compensation policy must be kept in effect at all times <br />LICENSE or CERTIFICATE NO (if applicable) <br />as required by law. <br />BUSINESS TELEPHONE NO. I FAX TELEPHONE NO. <br />52-345-0784 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 />Woodhill Country Club <br />DBA ("doing business as" or also known as an assumed name) (if applicable) <br />Woodhill Country Club <br />BUSINESS ADDRESS (must be physical street address, no PO boxes) CITY STATE ZIP CODE <br />200 Woodhill Road I Wayzata MIN 55393 <br />COUNTY E-MAIL ADRESS <br />Hennepin johnos@Ulrwternet.net <br />ternet.net <br />YOUR LICENSE OR CERTIFICATE WILL NOT BE ISSUED WITHOUT THE FOLLOWING <br />INFORMATION. You must complete number 1 or 1 below. <br />NUMBER 1 Workers' compensation insurance policy information <br />INSURANCE COMPANY NAME (not the insurance agent) MAIC Number. <br />fie. C. u rc- los o ryA-hc_,e_ Czf les ;L.;z 9 /3 <br />POLICY NO. EFFECTIVE DATE 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 />I8 have no employees. (see Minn. Stat. § 176.011, subd. 9 for the definition of an employee.) l am self-insured for workers' compensation (include a copy of authorization to sett -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. § 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 l 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) <br />TITLE <br />DATE <br />wv to/[1m, <br />NOTE: You must notN fis If th e s any change to your Workers' Compensation Insurance Information or Employee Status Change by resubmitting <br />this form. This material can beWde available in different forms, such as large print, Brallie or on a tape. htt�Www.dli.mn.MAYgPDFLmnii O4.odr <br />LIC 04 (9/12) <br />P"oa <br />