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Minnesota Statute, Section 176.182 requires every state and local licensing agency to withhold the issuance or renewal of a license or permit to operate a business or engage in an activity in Minnesota until the applicant presents acceptable evidence of compliance with the workers' compensation insurance coverage requirement of MSS Chapter 176. The information required is: The name of the insurance company, the policy number, and dates of coverage or the permit to self-insure. This information will be collected by the licensing agency and retained in their files. This information is required by law, and licenses and permits to operate a business may not be issued or renewed if it is not provided and/or is falsely reported. Furthermore, if this information is not provided or falsely stated, it may result in a $1,000 penalty assessed against the applicant by the Commissioner of the Department of Labor and Industry. Insurance Company Name: Policy Number: Dates of Coverage: to I am not required to have workers' compensation liability coverage because: I have no employees I am self insured (include permit to self-insure) I have no employees who are covered by the workers' compensation law I certify that the information provided above is accurate and complete and that a valid workers' compensation policy will be kept in effect at all times as required by law. Name: Doing Business As: Business name if different than your name Business Address: Telephone Number: Signature: Date: - CERTIFICATION OF COMPLIANCE - MINNESOTA WORKER'S COMPENSATION LAW (Not the Insurance Agent) or (these include: Spouse, Parents, Children, and certain farm employees) (Place an X in the box next to reason) (Street or PO Box) (City) State Zip code (MM) (DD) (YYYY)