Minnesota Department of Labor and Industry Construction Codes and Licensing by ramhood17

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									Minnesota Department of Labor and Industry
Construction Codes and Licensing Division                        Manufactured (Mobile) Home
Licensing / Manufactured Structure
443 Lafayette Road North
                                                          Business Certification of Compliance with the
St. Paul, MN 55155-4341                                     Minnesota Workers’ Compensation Law
Phone: (651) 284-5068 Fax: (651) 284-5749
www.doli.state.mn.us TTY: (651) 297-4198
                                                                                                    PRINT IN INK or TYPE your responses.


Complete the appropriate portions below, and sign and date the form. Mail to the above address.

OWNER’S LAST NAME                                        FIRST NAME                                           MIDDLE INITIAL



BUSINESS NAME



STATE I.D. NUMBER                           SOCIAL SECURITY NUMBER                         FEDERAL EMPLOYER I.D. NUMBER



ADDRESS



CITY                                                               STATE           ZIP CODE TELEPHONE NUMBER




Check Type of Business:          Manufacturer             Dealer               Installer

WORKERS’ COMPENSATION INSURANCE COMPANY                                                         POLICY NUMBER



INSURANCE AGENT’S NAME                                                                          TELEPHONE NUMBER



DATES OF COVERAGE (starting date)                                  THROUGH: (ending date)




I certify that I am not required to carry Workers’ Compensation Insurance because:    (check one)


     I am a sole proprietor or partner and I have no employees.

     I have no employees who are covered by the Workers’ Compensation Law. (Only employees specifically exempted by
     statute are not covered by the Workers’ Compensation Law. These include: Spouse; Parent; Children, regardless of age;
     and farm labor employees of a family that spent less than $8,000 for labor in the previous calendar year. All other workers
     whose work activity is controlled by the employer must be covered.


I understand that the information provided above will be verified and that I am subject to a $1,000 penalty if the information
provided is false. I certify that the information provided above is accurate and complete.

OWNER’S SIGNATURE                                                                                    DATE




This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354
(DIAL-DLI) Voice or TDD (651) 297-4198.




MS0508 (5/06)

								
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