Workers’ compensation

The below information is a guide to the information you will need when filling out the Workers’ compensation insurance coverage form. You are required to fill out this Workers’ compensation (PDF) form, providing the information requested and acknowledging your understanding and acceptance of the information below.

Please note: This is not the only form you will need to fill out to receive a food license. Please refer to the applying for a food license page for information and procedures on obtaining the other forms you will need when applying for a food license.

Workers’ compensation insurance coverage form

Minnesota Statute 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 Section 176.181, Subd. 2. The information required is: The name of the insurance company, the policy number, and dates of coverage or the permit to self-insure. This information will be collected by the licensing agency and put in its company file. It will be furnished, upon request, to the Department of Labor and Industry to check for compliance with Minnesota Statute Section 176.181, Subdivision 2.

This information is required by law, and licenses and permits to operate a business may not be issued or renewed if it is not provided and/or is falsely reported. Furthermore, if this information is not provided and/or falsely reported, it may result in a $2,000 penalty assessed against the applicant by the Commissioner of the Department of Labor and Industry payable to the Special Compensation Fund.

On the application, you will be required to provide the following information.

  • Worker’s Compensation Insurance Company Name(not agent’s name)
  • Policy Number
  • Dates of coverage (date coverage began and date coverage will end)

Or, you may certify that you am not required to carry worker’s compensation insurance because (check one):

  • I am the sole proprietor and have no employees
  • I am self insured (For this category, you must include a copy of the permit to self-insure.)
  • I have no employees who are covered by workers compensation law. (Only employees who are specifically exempted by statute are not covered by the workers compensation law. These include: spouse, parents, children—regardless of age, and farm labor employees of a family farm that spent less than $8,000 for farm labor in the previous calendar year. All other workers whose work is controllable by the employer must be covered.

On the form, you will need to provide signature and date, acknowledging the following:

I certify that all information provided above is accurate and complete. I also certify that a valid workers’ compensation policy will be kept in effect at all times, as required by law.