Form PS2420-07 "Certification of Compliance With Minnesota Worker's Compensation Law" - Minnesota

What Is Form PS2420-07?

This is a legal form that was released by the Minnesota Department of Public Safety - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2017;
  • The latest edition provided by the Minnesota Department of Public Safety;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form PS2420-07 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Public Safety.

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Download Form PS2420-07 "Certification of Compliance With Minnesota Worker's Compensation Law" - Minnesota

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OFFICE USE ONLY
Print Form
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DEALER NUMBER:
DRIVER AND VEHICLE SERVICES
DATE RECEIVED:
445 Minnesota Street, Suite 186
Saint Paul, MN 55101-5186
COUNTY:
Phone: (651) 201-7800 Fax: (651) 297-1480
AREA:
Web: dvs.dps.mn.gov Email: DVS.DealerQuestion@state.mn.us
INITIALS:
Certification of Compliance with Minnesota Worker's Compensation Law
This certification must accompany an application for a Minnesota Motor Vehicle Dealer's License
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 or engage in an activity in Minnesota until the applicant certifies that they are in compliance with the workers’
compensation coverage requirements outlined in section 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 and Industry.
You are required to fill the below portion out.
A valid workers' compensation policy must be kept in effect at all times by employers as required by law.
License or Certificate Number (if Applicable)
Business Telephone Number
Alternate Telephone Number
Dealership Name
DBA ("doing business as" or "also known as" an assumed name,) if applicable:
Business address (must be physical street address, no P.O. Boxes)
City
State
Zip code
County
Email Address
Workers' Compensation Insurance Policy Information
Insurance Company Name (Not the insurance agent)
NAIC Number
Policy Number
Effective Date
Expiration Date
Exemption
I am not required to have workers' compensation liability coverage because (please check one):
I have no employees. (See
Minnesota Statute § 176.011, subd. 9
for the definition of an employee.)
I am self-insured (attach permit to self insure).
I have no employees who are covered by the workers' compensation law (spouse, parents, children)
I certify that the information provided above is accurate and complete. I understand that if I have employees (who are
not a spouse, parent, or child), valid workers' compensation policy will be kept in effect at all times as required by law.
Print Name:
Applicant Signature (Required):
Title:
Date:
Note: You must notify the authority issuing your license is there is any change to your workers' compensation insurance information or an
employee status change by resubmitting this form. This material can be made available in different forms, such as large print, Braille or audio.
PS2420-07 (05/2017)
OFFICE USE ONLY
Print Form
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DEALER NUMBER:
DRIVER AND VEHICLE SERVICES
DATE RECEIVED:
445 Minnesota Street, Suite 186
Saint Paul, MN 55101-5186
COUNTY:
Phone: (651) 201-7800 Fax: (651) 297-1480
AREA:
Web: dvs.dps.mn.gov Email: DVS.DealerQuestion@state.mn.us
INITIALS:
Certification of Compliance with Minnesota Worker's Compensation Law
This certification must accompany an application for a Minnesota Motor Vehicle Dealer's License
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 or engage in an activity in Minnesota until the applicant certifies that they are in compliance with the workers’
compensation coverage requirements outlined in section 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 and Industry.
You are required to fill the below portion out.
A valid workers' compensation policy must be kept in effect at all times by employers as required by law.
License or Certificate Number (if Applicable)
Business Telephone Number
Alternate Telephone Number
Dealership Name
DBA ("doing business as" or "also known as" an assumed name,) if applicable:
Business address (must be physical street address, no P.O. Boxes)
City
State
Zip code
County
Email Address
Workers' Compensation Insurance Policy Information
Insurance Company Name (Not the insurance agent)
NAIC Number
Policy Number
Effective Date
Expiration Date
Exemption
I am not required to have workers' compensation liability coverage because (please check one):
I have no employees. (See
Minnesota Statute § 176.011, subd. 9
for the definition of an employee.)
I am self-insured (attach permit to self insure).
I have no employees who are covered by the workers' compensation law (spouse, parents, children)
I certify that the information provided above is accurate and complete. I understand that if I have employees (who are
not a spouse, parent, or child), valid workers' compensation policy will be kept in effect at all times as required by law.
Print Name:
Applicant Signature (Required):
Title:
Date:
Note: You must notify the authority issuing your license is there is any change to your workers' compensation insurance information or an
employee status change by resubmitting this form. This material can be made available in different forms, such as large print, Braille or audio.
PS2420-07 (05/2017)