Cpa Sole Proprietor Firm Permit Renewal Application - Minnesota Board Of Accountancy - 2017 Page 5

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2017 WORKERS’ COMPENSATION LIABILITY
CERTIFICATE OF COMPLIANCE
1.
Firm Information
Firm Name
Contact Name
Address
City
State
Zip
2.
Check the applicable option (A or B) and provide the requested details.
I have workers’ compensation liability coverage,
A.
and below is information regarding it:
Insurance Company:
Policy Number:
Dates of Coverage:
I am not required to have workers’ compensation
B.
liability coverage because:
The firm has no employees
I am self-insured
Note:
You must include a copy of your permit to self-insure with this form.
I have no employees who are covered by the workers’ compensation law
(Employed spouses, parents, and children are
exceptions
to coverage requirements.)
3.
Affidavit:
I certify that the information provided above is complete and accurate.
Signature
Date
Note: Minnesota Statute § 176.182
requires every state and local 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 workers’
compensation insurance coverage. If this information is not provided or is falsely stated, it may result in a penalty assessed
against the applicant by the Commissioner of the Department of Labor and Industry. This information will be collected by the
licensing agency and retained in their files.
CPA Sole Proprietor Firm Permit Renewal Form—Page 4 of 5

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