Proof of Workers Compensation Insurance Coverage
Mi
nnesota Statute Section 176.182 requires every state and local licensing agency to withhold the issuance or
renewal of a license or permit to operate a business or engage in an activity in Minnesota until the applicant
presents acceptable evidence of compliance with the workers’ compensation insurance coverage requirement of
MSS Chapter 176. The information required is: The name of the insurance company, the policy number, and
dates of coverage or the permit to self-insure. This information will be collected by the licensing agency and
retained in their files.
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. Furthermore, if this information is not provided and/or
falsely reported, it may result in a $2,000 penalty assessed against the applicant by the Commissioner of the
Department of Labor and Industry.
Provide the information specified above in the spaced provided, or certify the precise reason your business
is excluded from compliance with the insurance coverage requirement for workers’ compensation.
I am not required to have workers’ compensation liability coverage because:
I have no employees covered by the law.
I am self insured (include permit to self-insure)
I have no employees who are covered by the workers’ compensation law (these include: Spouse,
Parents, Children and certain farm employees)
State of Minnesota
SP:C1 License Applicant Information
Under Minnesota law (M.S. 270.72), the agency issuing you this license is required to provide the Minnesota
Commissioner of Revenue your Minnesota business tax identification number and the Social Security number of each
license applicant.
Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we must advise you that:
• This information may be used to deny the issuance, renewal or transfer of your license if you owe the
Minnesota Department of Revenue delinquent taxes, penalties, or interest;
• The Licensing agency will supply it only to
the Minnesota Department of Revenue. However, under the Federal
Exchange of Information Act, the Department of Revenue is allowed to supply the information to the Internal Revenue
Service;
• Failing to supply this information may jeopardize or delay the issuance of your license or processing your renewal
application.
• Please fill in the following information and return this form along with your application to the agency issuing the
license. Do not return this form to the Department of Revenue.
Personal information:
___________________________________________________________________________________________
Applicant’s last name
First name
Middle name
Date of birth
___________________________________________________________________________________________
Applicant’s address City State
Zip
Code
___________________________________________________________________________________________
Business name
___________________________________________________________________________________________
Business address City State Zip Code
___________________________________________________________________________________________
Minnesota tax identification number
Federal tax identification number
___________________________________________________________________________________________
Signature Title Date
