3.8 Tobacco License - Laserfiche WebLink

Home Browse Search

osub ' " '" Certificate of Compliance Minnesota Workers' Compensation Law THIS FORM MUST BE COMPLETED BY THE BUSINESS LICENSE APPLICANT PRINT IN INK or TYPE Minnesota Statutes§176.182 requires every state and local licensing agency to withhold the issuance or renewal of a license or permit to operate a business in Minnesota until the applicant presents acceptable evidence of compliance with the workers' compensation insurance coverage requirement of Minnesota Statutes Chapter 176. If the required information is not provided or is falsely stated it shall result in a$2,000 penalty assessed against the applicant by the commissioner of the Department of Labor and Industry. A valid workers' compensation policy must be kept in effect at all times by employers as required by law. License or certificate number(if applicable) Business telephone number Alternate telephone number Business name(Provide the legal name of the business entity.If the business is a sole proprietor or partnership,provide the owner's name(s),for example John Doe,or John Doe and Jane Doe.) DBA("doing business as"or"also known as"an assumed name),if applicable Business address(must be physical street address,no P.O.boxes) City State ZIP code County Email address YOUR LICENSE OR CERTIFICATE WILL NOT BE ISSUED WITHOUT THE FOLLOWING INFORMATION. You must complete number 1 or 2 below. Number 1 — Workers' compensation insurance policy information Insurance company name(not the insurance agent) NAIC number Policy number Effective date Expiration date Number 2 — Reason for exemption from workers' compensation insurance If you have questions regarding the need to obtain workers'compensation coverage, including exemptions, call (651)284-5032 or 1-800-342-5354. ®l have no employees. (See Minnesota Statute§ 176.011, subd. 9 for the definition of an employee.) ®I am self-insured for workers'compensation (attach a copy of the authorization to self-insure from the Minnesota Department of Commerce). ®I have employees but they are not covered by the workers' compensation law. (See Minnesota Statute 4 176.041 for a list of excluded employees.)Explain why your employees are not covered: I certify the information provided on this form is accurate and complete. If I am signing on behalf of a business, I certify I am authorized to sign on behalf of the business. Print name Applicant signature(required) Title Date NOTE: You must notify the authority issuing your license if there is any change to your workers'compensation insurance information or an employee status change by resubmitting this form.This material can be made available in different forms,such as large print,Braille or audio. LIC 04(5/15)