Certificate of Compliance Minnesota Workers' Compensation Law - doli state mn 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your business name in the designated field. If you are a sole proprietor or partnership, use the personal names (e.g., John Doe). For other business structures, input the legal entity name.
3. Fill in your business address, ensuring to provide a physical street address without using a P.O. box. Include city, county, state, and ZIP code.
4. Provide your business telephone number and fax number if applicable. Also, include an email address for communication purposes.
5. Select either option 1 or option 2 regarding workers’ compensation insurance. If you have coverage, enter the insurance company name, policy number, NAIC number, effective date, and expiration date.
6. If claiming an exemption from coverage under option 2, check the appropriate box and provide any necessary explanations as required.
7. Finally, certify that all information is accurate by signing and dating the form. Ensure that you print your name and title if signing on behalf of a business.

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