Worker'S Compensation Insurance Certification Business License Addendum Form

WORKER’S COMPENSATION INSURANCE CERTIFICATION

BUSINESS LICENSE ADDENDUM

I,______________________________________________________, certify that:

____I have the necessary Worker’s Compensation Insurance coverage as required by state

law to do business in Missouri.

____I am exempt because I have fewer than five (5) employees [one (1) if construction].

Further, I understand that, in addition to other penalties and sanctions as provided by state

law, I am subject to revocation of the business license issued by the City of Fulton if I do not

maintain adequate worker’s compensation coverage as required by state law.

Business Name:

______________________________________________________

(please print)

Signature: ________________________________________

Title: _________________________________________

Date: _________________________________________

NOTE: The above addendum must be filled out and returned with your

business license application or your license will not be issued

BUSINESS LICENSE RENEWAL INFORMATION

Please remember to enclose the following items (your license will not be issued without them):

a. A copy of 2015 paid tax receipts paid for any Personal Property and/or Real Estate, owned by

yourself and/or your business, located within the Fulton City Limits. (This was paid at the Callaway

County Courthouse, Fulton, MO). As per Fulton City Code: “No license or permit shall be issued to

any person owing the city any delinquent personal, merchants’, or other city taxes until such taxes

shall be paid in full to the city.” This debt includes any unpaid Personal Property and/or Real Estate

Taxes for your business and/or yourself if located within Fulton City Limits. If you live and have a

business outside the City Limits, mark the lower right hand corner of the renewal form N/A. Any

business opened in Fulton during 2015 is not required to provide a paid tax receipt for the business.

b. Completed Workman’s Compensation Insurance Certification Addendum (attached above)

c. License renewal fee (see schedule on attached application)

d. Missouri Tax Identification Number if you collect retail sales tax. (see attached application )

If available, please enclose a copy of your ‘Certificate of No Tax Due’ provided by the

Missouri Department of Revenue.

Please contact the City Clerk’s Office at (573)592-3111 if you do not intend to renew your business

license. Thank you.

Worker'S Compensation Insurance Certification Business License Addendum Form - City Of Fulton