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collected by the licensin6 attency and retained in their files. <br /> This information is required by law,and licenses and permits to operate a business may not be issued or renewed if it is not <br /> provided and/or is falsely reported.Furthermore,if this information is not provided or falsely stated,it may result in a$2,()00 <br /> penalty assessed against the applicant by the Commissioner of the Department of Labor and Industry. <br /> Insurance Company Name: <br /> Ng the Insurance Agent) <br /> Policy Number: <br /> Dates of Coverage: to <br /> (or) <br /> I am not required to have Workers'Compensation liability coverage because: <br /> ( ) I have no employees <br /> ( ) I am self-insured(include permit to self-insure) <br /> ( ) I have no employees who are covered by the Workers'Compensation law(these include:spouse,parents,children and <br /> certain farm employees) <br /> I certify that the information provided above is accurate and complete and that a valid Workers'Compensation policy will be <br /> kept in effect at all times as required by law. <br /> Name: <br /> (Last,First,Middle) <br /> Doing Business As: (Business name if <br /> different than your name) <br /> Business Address: <br /> City,State,Zip. Phone:( ) <br /> Signature: Date: <br /> V <br />