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 Minn. Stat. 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) County City Email address State ZIP code You must complete number 1 or 2 below. Note: You must resubmit this form to the authority issuing your license if any of the information you have provided changes. 1. I have a workers' compensation insurance policy. Insurance company name (not the insurance agent) Policy number Effective date Expiration date I am self-insured for workers' compensation. (Attach a copy of the authorization to self-insure from the Minnesota Department of Commerce; see www.mn.gov/commerce/industries/insurance/licensing/self-insurance.) 2. I am not required to have workers' compensation insurance because: I only use independent contractors and do not have employees. (See Minn. Stat. § 176.043 for trucking and messenger courier industries; Minn. Stat. § 181.723, subd. 4, for building construction; and Minnesota Rules chapter 5224 for other industries.) I do not use independent contractors and have no employees. (See Minn. Stat. § 176.011, subd. 9, for the definition of an employee.) I use independent contractors and I have employees who are not required to be covered by the workers' compensation law. (Explain below.) I only have employees who are not required to be covered by the workers' compensation law. (Explain below.) (See Minn. Stat. § 176.041 for a list of excluded employees.) Explain why your employees are not required to be 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 If you have questions about completing this form or to request this form in Braille, large print or audio, call (651) 284-5032 or 1-800-342-5354. LIC 04 (11/16) American LegalNet, Inc. www.FormsWorkFlow.com