Minnesota Department of Labor and Industry
Construction Codes and Licensing Division
Licensing and Certification Services
443 Lafayette Road North
St. Paul, MN 55155
Mailing Address:
PO Box 64217
St. Paul, MN 55164-0217
E-mail: dli.license@state.mn.us
Web Site: www.dli.mn.gov/ccld.asp
Directions: http://www.dli.mn.gov/Direct.asp
Phone: (651) 284-5034
Certificate of Compliance
Minnesota Workers’ Compensation Law
THIS FORM MUST BE COMPLETED AND SIGNED
BY ALL BUSINESS TYPES
PRINT IN INK or TYPE.
Minnesota Statutes, 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 in Minnesota until the applicant presents acceptable evidence of compliance with the
workers' compensation insurance coverage requirement of Minnesota Statutes, Chapter 176. If the required information is not
provided or is falsely stated, it shall result in a $2,000 penalty assessed against the applicant by the commissioner of the
Department of Labor a
nd Industry.
A valid workers’ compensation policy must be kept in effect at all times by employers as required by law.
CONTRACTOR’S LICENSE or REGISTRATION NO (if applicable) BUSINESS TELEPHONE NO. FAX TELEPHONE NO.
BUSINESS NAME (Use the person(s) name if business structure is sole proprietor or partnership (i.e., John Doe, or John Doe and Jane Doe), otherwise it is
the legal name of the business entity.)
DBA NAME
(Doing business as name / assumed name – if applicable
)
BUSINESS ADDRESS (must be physical street address, no PO boxes)
YOUR LICENSE OR REGISTRATION WILL NOT BE ISSUED WITHOUT THE FOLLOWING
INFORMATION. You must complete number 1 or 2 below.
NUMBER 1 – Workers’ compensation insurance policy information
INSURANCE COMPANY NAME (not the insurance agent)
NUMBER 2 – Reason for exemption from workers’ compensation insurance
If you have questions regarding the need to obtain workers’ compensation coverage, including exemptions, contact
651.284.5032:
I have no employees. (See Minn. Stat. § 176.011, subd. 9 for the definition of an employee)
I am self-insured for workers’ compensation (include a copy of authorization to self-insure from the Minnesota Department
of Commerce).
I have employees but they are not covered by the workers’ compensation law. (See Minn. Stat. § 176.041 for a list of
excluded employees) Explain why your employees are not covered:
Other:
I certify that the information provided on this form is accurate and complete.
APPLICANT SIGNATURE (mandatory) TITLE DATE
NOTE: You must notify us if there is any change to your Workers’ Compensation Insurance Information or Employee Status Change by resubmitting this form.
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.
CC0515 Work Comp Compliance (12/12)
