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Mn workers comp exemption form

Certificate of compliance minnesota workers compensation law 2026

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The document is a Certificate of Compliance for Minnesota Workers’ Compensation Law, which requires businesses to provide proof of workers' compensation insurance or an exemption to obtain or renew a business license. It outlines the necessary information needed, including business details and insurance policy specifics, and warns of penalties for non-compliance.

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Click ‘Get Form’ to open the certificate of compliance in our editor.
Begin by filling in your business details. Enter your business name, telephone number, and address. Ensure that the information is accurate and printed clearly.
Next, provide your workers' compensation insurance policy information if applicable. Fill in the insurance company name, policy number, NAIC number, effective date, and expiration date.
If you are exempt from workers' compensation insurance, select the appropriate reason from the options provided. Be sure to explain any exclusions clearly in the designated area.
Finally, certify that all information is accurate by signing the form. Include your title and date of signing before submitting.

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Versions	Form popularity	Fillable & printable
2016	4.8 Satisfied (131 Votes)
2012	4.1 Satisfied (37 Votes)

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workers comp exemption form

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Certificate of compliance minnesota workers compensation law 2026

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