Application For Minnesota Cpa Firm Permit - Minnesota Board Of Accountancy Page 5
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6WORKERS’ 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.
A.
I have workers’ compensation liability coverage,
and below is information regarding it:
Insurance Company:
Policy Number:
Dates of Coverage:
B.
I am not required to have workers’ compensation
liability coverage because:
The firm has no employees.
I have no employees who are covered by the workers’ compensation law.
(Employed spouses, parents, and children are
exceptions
to coverage requirements.)
I am self-insured and am including a copy of my permit to self-insure with this form.
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 insur-
ance coverage. If this information is not provided or is falsely stated, it may result in a penalty assessed against the applicant by the Commission-
er of the Department of Labor and Industry. This information will be collected by the licensing agency and retained in their files.
Application for CPA Firm Permit—Page 4 of 5
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