CERTIFICATE OF COMPLIANCE WITH MINNESOTA WORKERS' COMPENSATIONLAW Minn. Stat. § 176.182

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MN Worker's Comp Form
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. In addition, the County shall not enter into a contract for the doing of any public work before receiving acceptable evidence of compliance with workers' compensation insurance coverage requirements. Furthermore, if this information is not provided or is falsely stated; it may result in a $2,000 penalty assessed against the applicant by the Commissioner of the Department of Labor and Industry.
Insurance Company Name (Not the insurance agency):
Policy Number:
Dates of Coverage:
Coverage Start Date
Month - Day - Year
Coverage End Date
Month - Day - Year
OR
Applicant is not required to have worker's compensation liability coverage because:
Check one
Applicant has no employees
Applicant is self-insured (include a copy of your permit to self-insure)
Applicant has no employees who are covered by workers' compensation
OR
Certificate of Insurance is attached
Upload Certificate of Insurance:
Filename
Size
Process
Status
Add Files Start Upload
If "Certificate of insurance is attached" selected above, you must upload copy of proof of insurance.
Grantee/Contractor:
Company/Business Name:
Email
Datetime
Month - Day - Year
Fullname

First Name
Last Name
Signature:

MN Worker's Comp Form