STATE OF MINNESOTABoard of Private Detective and Protective Agent Services 1430 Maryland Avenue East, St. Paul MN 55106

Dear License Holders,

Our agency has been spending a great deal of time each month to work with license holders to complete their renewal applications due to simple issues contained within the required paperwork. Though we have provided detailed instructions and checklists, we are still finding several issues with almost all renewal applications we receive.

Below is an analysis of an audit conducted on 18 months of renewals:

TYPE OF ISSUE %Number With Issues 87.37%Turned In Application Late 20.48%Application Not Completely Filled Out 13.68%CEO/CFO/MN Manager/Qualified Representative Does Not Match File 10.53%Affidavit of Training Not Completely Filled Out/Not Provided 23.16%Affidavit of Training Didn't List Qualified Representative or MN Manager 6.32%Missed Preassignment Window 5.26%No Post Certificate Received 6.32%Employee(s) Did Not Complete Preassignment Within 21 Days 7.37%Did Not Provide Number Of Employees And/or Employee List 6.32%Bond Issues 5.26%Gap In Insurance/Issues With Insurance Certificate 24.21%Workers Compensation Form Not Filled Out/And Or Signed 6.32%Wrong Amount On Check/No Check Received 15.79%Criminal History Consent Forms Not Sent In 6.32%Continuing Training Hours Do Not Meet Statutory Requirements 15.79%

In order to assist you with this process, we have attached a renewal self-audit tool for you to utilize while completing your renewal application. As this is the checklist our staff uses when processing your renewals, there will not be much room for justification of blanks spots on the application, required documentation not being received, or other important information missing on the renewal application.

We understand you do not wish to be penalized or placed into contingency status. The Board takes no pleasure in disciplining license holders when they submit an incomplete renewal application. Agency staff time could be more beneficially spent being proactive and working on projects to assist license holders and improve the quality of the industry.

With that being said, I would highly advise putting the attached Self Audit to use to help eliminate hassles for all parties concerned. This will be presented at a future Board meeting to make the use of the Self Audit mandatory. We are also attaching an electronic Excel Spread

Please let us know if you have any questions,

Hugo McPheeExecutive DirectorMinnesota Board of Private Detectives and Protective Agents

License Holder Renewal Self - Audit YES NO N/ADid the agency receive the renewal application on or before the deadline (First of the Month)?If the application was received after the deadline, did you provide an explanation as to why it was late?Did you answer the following question on the renewal application: DESCRIBE THE ROLE WHICH THE LICENSED APPLICANT PLAYS IN THE SUPERVISION AND MANAGEMENT OF THE LICENSED BUSINESSES (be specific):Is the application legible and complete?Is every line filled in on the application (dates, signatures, etc.) so there are no blank spaces?If a corporate license - Is the CFO listed, correct, and did they sign the renewal?If a corporate license - Is the CEO listed, correct, and did they sign the renewal?If a corporate license - Is the Qualified Representative (QR) listed, correct and did they sign the renewal?If a corporate license, and is out of state - Is the Minnesota Manager (MM) listed, correct and did they sign the renewal?Is a Minnesota address (either physical or registered agent) listed? This is required.If the address has changed within the renewal period was the Board notified?Are the current number of employees provided and correct (license holders, partners, QRs and MM are included)?Did you provide the correct check amount?Did you provide a Criminal History Consent form for each person signing the application?Was an Affidavit of Training (AOT) provided (required for all renewals)?Is the license number and company/license holder name provided at the top of the AOT?Is the AOT signed and dated at the bottom?Has a BCA/FBI background check completed for all employees (including license holders, partners, QRs and MMs)?Were the BCA/FBI criminal record results received and clear prior to any employees performing licensable services?Did all employees receive an I.D. card and have the date they were issued it listed on the AOT?Did all employees complete Preassignment Training within the statutorily required 21 days of hire?Is the continuing education for all employees completed annually within the renewal period (renewal month to renewal month)?Is there a 1st and 2nd year continuing education course number and date the course was completed for all employees including the license holder, partner, MM, and QR?Are course numbers listed for all preassignment training as well as for the first and second year of continuing education training?Have these course numbers been verified as certified courses?Did you indicate whether or not each employee is armed or unarmed by providing a Y or N in the "Armed" column on the AOT?Did you sign and date the bottom page of the armed AOT?If you indicated armed employees on the AOT, did those employees get listed on the armed AOT as well?If listed on the armed AOT, do all employees have a date for when they were first in an armed capacity?Does each armed employee have all weapon(s) they carry while in their armed capacity listed?Did each armed employee receive their initial armed training prior to their start date in an armed capacity?Did each armed employee receive their continuing armed training within the renewal period (renewal month to renewal month)?Are there course numbers listed for all initial armed and continuing education training?Have these armed course numbers been verified as certified courses?Is the license number and company/license holder name provided at the top of the AOT?Is the AOT signed and dated at the bottom?Is your bond number accurate?Did you provide Proof of Financial Responsibility (Net Worth Statement Signed off by a CPA, Irrevocable Letter of Credit from a Bank, General Liability Insurance Certificate - Accord 25 Form)?If you chose a general liability insurance policy, did you include certificates of coverage for your entire renewal period?Have you had continuous proof of financial responsibility coverage?Did you provide a completed Workers Compensation form?

Completed by: Date:

STATE OF MINNESOTABoard of Private Detective and Protective Agent Services 1430 Maryland Avenue East, St. Paul MN 55106

Dear License Holder,

The Private Detective and Protective Agent Services Board will be considering license reissuance applications at their monthly board meeting. The license reissuance process is noted in M.S. §326.3383, subd. 1.

The return deadline is the first of the month in which your license expires. You are encouraged to send in your materials prior to that date. Failure to return all reissuance materials may result in delays, or the license may not be reissued. Timely return will allow ample time to process the application and for board review. If there are problems concerning a reissuance, you will be informed of those issues and necessary response. The board typically meets the last Tuesday of each month to consider reissuance applications for that month (check the calendar on our website for the exact date). Following that meeting, your reissued license and materials will be sent. If you should choose not to seek license reissuance please contact me.

Enclosed are the materials necessary for you to complete. Please review and refer to the statutes and administrative rules when you are completing the application and other necessary paperwork. Take special note of the checklist on the application. This will help ensure all necessary items have been completed.

Renewal Fee Structure:There is much confusion among license holders regarding whether or not they have ‘0’ or ‘1’ employee in calculating their renewal fee. You can read more about this once our October 2013 Meeting Minutes are posted at https://dps.mn.gov/entity/pdb/board- meetings/Pages/minutes.aspx

The new renewal fee structure beginning January 1st, 2014 is:

REISSUANCE

For the purposes of calculating the number of employees; the Board uses the following equation as provided in administrative rule:

7506.0140 FEES. Subp. 2. License reissuance fees. The fees for a reissuance of a license are set according to the number of employees.For purposes of this subpart only, an applicant shall determine the number of employees as described in items A to C.

A. Count as one employee each person who regularly works an average of 30 or more hours per week performing duties as described in Minnesota Statutes, section 326.338, subdivisions 1 and 4.

B. Total the annual hours worked by persons hired periodically or who regularly work less than 30 hours per week performing duties as described in Minnesota Statutes, section 326.338, subdivisions 1 and 4. Divide that total by 1500.

C. Total the figures from items A and B to calculate the number of employees to use when determining the appropriate fee. NOTE: Corporate, Limited Liability Company, and Partnership license holders must include the Qualified Representative and Minnesota Manager, as well as any corporate/company officer who carries out licensed activity.

PLEASE MAKE CHECKS OR MONEY ORDERS PAYABLE TO:“Private Detective and Protective Agent Services Board”

Pilot Cars CertificationOn January 1st, 2014 the certification of pilot car drivers with the state of Minnesota was enacted. Recent revision in the statutes state that no other certification or license is required for providing this service. If you currently have a protective agent license for the sole purpose of providing pilot car services this license is no longer required. Please contact our agency if you have any questions.

Please review the following statutes and rules:

Private Detective Protective Agent*0 -1 Employees $ 540.00 *0 -1 Employees $ 480.00*2 to 10 Employees $ 710.00 *2 to 10 Employees $ 650.0011 to 25 Employees $ 880.00 11 to 25 Employees $ 820.0026 to 50 Employees $1,050.00 26 to 50 Employees $ 990.0051 or more employees $1,220.00 51 or more employees $1,160.00

o Minnesota Administrative Rule Chapter 7455: PILOT VEHICLE ESCORT FOR OVERDIMENSIONAL LOAD This can be found at: https://www.revisor.mn.gov/rules/?id=7455

o Minnesota Statute: 299D.085: OVER DIMENSIONAL LOAD ESCORT DRIVER This can be found at: https://www.revisor.mn.gov/statutes/?id=299D.085

o Another helpful link is: http://mn.gov/elicense/licenses/licensedetail.jsp?URI=tcm:29-4102&CT_URI=tcm:27-117-32o There are training classes being provided, one being from Hennepin Technical College:

http://hennepintech.edu/customizedtraining/cts/100

Be advised, the Minnesota Board of Private Detectives and Protective Agent Services does not regulate this certification program. For more information please contact:

Minnesota Department of Public Safety (DPS), 445 Minnesota StreetSt. Paul, MN 55101(651) 201-7000 | (651) 282-6555 (TTY)

Minnesota State Patrol445 Minnesota St., Suite 130, St. Paul, MN 55101 Commercial Vehicle Section(651) 201-7100 | (651) 282-6555 (TTY

It is this agency’s goal is to reduce the number of renewals that get sent back or get delayed due to discrepancies. I am finding some common issues and want to clear these up before you send in your packet:

1. Beginning January 1st, 2014 there was a new renewal fee schedule (please see attached). When you are figuring out your fee payment only count employees that are employed in Minnesota.

2. Please make sure to complete the Workers Compensation form. Be advised this is a state required form that is audited by the Department of Labor. If you do not have any employees you must still complete the bottom portion.

3. The Board has decided that everyone must complete and sign an Affidavit of Training, even if you are an individual with no employees. Please fill in each appropriate blank on the form legibly.

4. If you took training classes that are not listed as certified by the Board these need to be pre-approved.5. Please submit copies of your insurance certificates that pertain to the renewal period. This would include certificates that

were in effect for past 2 years. I realize that your insurance company sends our agency these items, but it would assist us greatly in expediting the renewal process if you can provide copies with your packet.

6. Be advised that if we do not receive your packet by the first of the month in which it is due it will be marked as late. The Board may impose a penalty. If you have a situation that prohibits getting the packet in on time contact me.

7. Though I am sending you an electronic version I do need you to mail me back a hard copy.8. If your packet is complete it will be presented at the Board meeting for Board approval. You will be notified after the Board

meeting of the status.9. Our agency will then change your database to reflect your next renewal date which will be two years from the date of

approval.10. We will then mail you out your new certificate.

As always, I am here to assist you with the process. It is my goal to make this process as smooth as possible and have no contingencies (delayed renewals). I am working with the Board to streamline our processes and remove the bureaucracy. Some changes take Board approval; others require legislative approval, which is a significantly longer process. One initiative I have begun is having the renewal process done online, but for now the paper application is what we are dealing with.

If you run into any issues during your renewal process, have questions or expect delays, please contact me promptly at Hugo.McPhee@state.mn.us (email preferred) or call at (651)793-2669. Please do not wait until the due date to notify us that you cannot meet the deadline.

Sincerely,

Hugo McPheeExecutive DirectorMinnesota Board of Private Detective and Protective Agent Services Hugo.McPhee@state.mn.usPhone: (651) 793-2669TTY 651/282-6555

Form R-2004STATE OF MINNESOTA BOARD OF PRIVATE DETECTIVE AND PROTECTIVE AGENT

SERVICES LICENSE REISSUANCE APPLICATION: INDIVIDUAL

Select one: PRIVATE DETECTIVE PROTECTIVE AGENT Current License #: Expiration Date:BUSINESS NAME (if any):Any “doing business name(s)” used in association with your license must be registered with the MN Secretary of State.

MINNESOTA ADDRESS: MINNESOTA BUSINESS PHONE: ( ) MINNESOTA FAX: ( ) APPLICANT EMAIL:$10,000 SURETY BOND COMPANY: BOND #:# OF EMPLOYEES CURRENTLY WORKING FOR THE BUSINESS AUTHORIZED UNDER THIS LICENSE (including the license holder):

HAVE BACKGROUND CHECKS AND CRIMINAL RECORD CHECKS BEEN PERFORMED ON ALL PERSONNEL IN THE EMPLOYOF THE LICENSED BUSINESS (including the applicant who holds the license)? Y NHAVE THE LICENSED APPLICANT OR ANY EMPLOYEES BEEN CONVICTED OF ANY DISQUALIFYING ACT SPECIFIED IN MINNESOTA STATUTES §326.3381, Subd. 3 (1) ? Y N If so, specify:

DESCRIBE THE ROLE WHICH THE LICENSED APPLICANT PLAYS IN THE SUPERVISION AND MANAGEMENT OF THE LICENSEDBUSINESSES (be specific):

CHECKLIST: (Please complete the following checklist by placing an X to the left of the item)All information on this form including signatures has been completed and is legible and correct.All officer positions have been filled out on the application and are correct.Reissuance fees enclosed in the form of two separate checks or money orders, payable to the MN Private Detective and Protective Agent Services Board.Informed Consent Renewal completed by each individual signing the application.A completed Affidavit of Training form as well as a separate and completed Armed Affidavit of Training form (if armed), with all forms meeting the criteria. A completed Affidavit of Employee Training is required for all renewals, this includes sole proprietors, Minnesota Managers, Qualified Representatives, and all employees. Any employee who is a Minnesota licensed peace officer is exempt from training requirements but you must provide a copy of that employee’s Minnesota peace officer license and list them on the Affidavit of Training indicating they are POST certified. No employee can carry or use a weapon (while carrying out licensable duties) without first successfully completing Board approved training.Appropriate documentation of proof of financial responsibility for both years that fell within the license period (MS§326.3382, Subd. 3(c)). Liability insurance must be provided on an Acord 25 with the Certificate Holder listed as follows: MN Board Private Detective and Protective Agents, 1430 Maryland Ave E, St. Paul, MN 55106Completed Worker’s Compensation Compliance form (MS §176.182).

ACKNOWLEDGMENT AND VERIFICATION

I affirm that all information and documentation in this reissuance application is true and correct and that I have completed each item on the checklist and filled out the checklist. I affirm that I have read MS §326.32-326.339 and Administrative Rules 7605.0100-7506.2900.

APPLICANT: Signature Date

1

Affidavit of Training*All fields on this form are required for each employee, Minnesota Managers, and Qualified Representatives

Employee Name (Last, First)*Qualified Representatives

and Minnesota Managers are considered employees

MinnesotaHire Date

(MM/DD/YY)

Date (MM/DD/YY) BCA& FBI Background

Checks Completed

Date(MM/DD/YY) ID

Card Issued*Applicable to all

employees, Minnesota

Managers, and Qualified

Representatives

Date (MM/DD/YY) Preassignment

Training Completed

*To be taken within 21 days of hire

date.

Preassignment Training Course

Number

Dates (MM/DD/YY) of Continuing Training and Course NumbersArmed?Yes/No

(If yes, complete page 2)

BCA FBI

1st YearContinuing Training Date (MM/DD/YY)

1st YearContinuing Training Course Number

2nd YearContinuing Training Date (MM/DD/YY)

2nd YearContinuing Training Course Number

COLUMN 1COLUMN

2COLUMN

3COLUMN

4COLUMN

5COLUMN

6COLUMN

7COLUMN

8COLUMN

9COLUMN

10COLUMN

11COLUMN

12

Affidavit of Training (AOT) Instructions

Column A: Employee Name (Last, First) This column is to list each employee currently employed and conducting licensable activity under your

private detective or protective agent license. All Sole Proprietors, Qualified Representatives and Minnesota Managers are to be counted as an

employee and listed on the AOT. This applies even if the Qualified Representatives and/or Minnesota Managers do not reside in the state or personally operate in the state.

Column B: Minnesota Hire Date (MM/DD/YY): The Board discussed the term of hire date at a previous board meeting. Their conclusion was that “Hire

Date” could also be considered their “Minnesota Start Date”. This date would be the date in which the employee begins on the payroll in Minnesota.

Please be sure to input this date with the correct (MM/DD/YY) format.Column C & D: Date (MM/DD/YY): BCA & FBI Background Checks Completed:

Please be sure to input the correct BCA and FBI background check dates with the correct (MM/DD/YY) format.

These should be the dates the employee(s), including Sole Proprietors, Minnesota Managers and Qualified Representatives, were originally hired on in their capacity.

Column E: Date (MM/DD/YY) ID Card Issued: Per the following Minnesota Statute, each employee, Sole Proprietor Minnesota Manager, and

Qualified Representative conducting licensable activities under the private detective or protective agent license, must be issued an Identification Card. Currently, it is the responsibility of the license holder to provide these ID cards.

326.336 EMPLOYEES OF LICENSE HOLDERS.Subd. 2.Identification card.

An identification card must be issued by the license holder to each employee. The card must be in the possession of the employee to whom it is issued at all times. The identification card must contain the license holder's name, logo (if any), address or Minnesota office address, and the employee's photograph and physical description. The card must be signed by the employee and by the license holder, qualified representative, or Minnesota office manager.

Please be sure to input the correct date that each individuals’ ID cards are issued and write them in the correct (MM/DD/YY) format.

Column F: Date (MM/DD/YY) Preassignment Training Completed: Each employee, Sole Proprietor, Qualified Representative, and Minnesota Manager is subject to

completing Board Certified Preassignment training. This training must be completed within 21 days of the employee, Sole Proprietor, Qualified

Representative, and Minnesota Manager’s hire/start date per Minnesota Statute. Please be sure to input the correct preassignment date in the correct (MM/DD/YY) format.

Column G: Preassignment Training Course Number: Each certified training course is assigned a specific course number. After the completion of each course, a certificate of completion should be received with the specific

course number. This course number is to be kept for your records as well as placed in this column of the AOT.

Affidavit of Training (AOT) Instructions

Column A: Employee Name (Last, First) This column is to list each employee currently employed and conducting licensable activity under your

private detective or protective agent license. All Sole Proprietors, Qualified Representatives and Minnesota Managers are to be counted as an

employee and listed on the AOT. This applies even if the Qualified Representatives and/or Minnesota Managers do not reside in the state or personally operate in the state.

Column B: Hire Date (MM/DD/YY): The Board discussed the term of hire date at a previous board meeting. Their conclusion was that “Hire

Date” could also be considered their “Start Date”. This date would be the date in which the employee begins on the payroll.

Please be sure to input this date with the correct (MM/DD/YY) format.Column C & D: Date (MM/DD/YY): BCA & FBI Background Checks Completed:

Please be sure to input the correct BCA and FBI background check dates with the correct (MM/DD/YY) format.

These should be the dates the employee(s), including Sole Proprietors, Minnesota Managers and Qualified Representatives, were originally hired on in their capacity.

Column E: Date (MM/DD/YY) ID Card Issued: Per the following Minnesota Statute, each employee, Sole Proprietor Minnesota Manager, and

Qualified Representative conducting licensable activities under the private detective or protective agent license, must be issued an Identification Card. Currently, it is the responsibility of the license holder to provide these ID cards.

326.336 EMPLOYEES OF LICENSE HOLDERS.Subd. 2.Identification card.

An identification card must be issued by the license holder to each employee. The card must be in the possession of the employee to whom it is issued at all times. The identification card must contain the license holder's name, logo (if any), address or Minnesota office address, and the employee's photograph and physical description. The card must be signed by the employee and by the license holder, qualified representative, or Minnesota office manager.

Please be sure to input the correct date that each individuals’ ID cards are issued and write them in the correct (MM/DD/YY) format.

Column F: Date (MM/DD/YY) Preassignment Training Completed: Each employee, Sole Proprietor, Qualified Representative, and Minnesota Manager is subject to

completing Board Certified Preassignment training. This training must be completed within 21 days of the employee, Sole Proprietor, Qualified

Representative, and Minnesota Manager’s hire/start date per Minnesota Statute. Please be sure to input the correct preassignment date in the correct (MM/DD/YY) format.

Column G: Preassignment Training Course Number: Each certified training course is assigned a specific course number. After the completion of each course, a certificate of completion should be received with the specific

course number. This course number is to be kept for your records as well as placed in this column of the AOT.

License # Company / License Holder Name Form# T 3007‐

Affidavit of Training* All fields on this form are required for all employees, Minnesota Managers, Qualified Representatives and Sole Proprietors

Employee Name (Last, First)*Qualified Representatives and

Minnesota Managers are considered employees

MinnesotaHire Date

(MM/DD/YY)

Date (MM/DD/YY) BCA & FBI Background Checks

Completed

Date (MM/DD/YY) ID Card Issued *Applicable

to all employees, Minnesota Managers,

and Qualified Representatives

Date (MM/DD/YY) Preassignment Training

Completed*To be taken within 21

days of hire date.

Preassignment Training Course

Number

Dates (MM/DD/YY) of Continuing Training and Course Numbers Armed?Yes/No

(If yes, complete page 2)

BCA FBI1st Year Continuing Training Date (MM/DD/YY)

1st Year Continuing Training Course Number

2nd Year Continuing Training Date (MM/DD/YY)

2nd Year Continuing Training Course Number

License Holder Signature: Date Completed:This form is available on our website https://dps.mn.gov/entity/pdb, under the training area "Compliance Documents", in WORD and EXCEL formats taht will allow you to enter information and save to your computer. You may also copy this form as needed ‐for your use.

Affidavit of Armed Training*All fields on this form are required for all armed employees, Minnesota Managers,

and Qualified Representatives

Employee Name (Last, First)*Qualified Representatives and Minnesota Managers are considered employees

Weapon Type(s)

Date (MM/DD/YY)

of Initial Armed Training

Initial Armed Course

Number

Dates (MM/DD/YY) of Continuing Armed Training and Course Number

1st Year Continuing

Training Date

1st Year Continuing

Training Course

2nd Year Continuing

Training Date

2nd Year Continuing

Training Course

Number

COLUMN A COLUMN B COLUMN C COLUMN D

COLUMN E

COLUMN F COLUMN G COLUMN H

License # Company / License Holder Name FORM# T 3008‐

Affidavit of Armed Training* All fields on this form are required for all armed employees, Minnesota Managers, and Qualified Representatives

Employee Name (Last, First)*Qualified Representatives and

Minnesota Managers are considered employees

Hire/Start Date in Armed Capacity (MM/DD/YY)

Weapon Type(s)Date (MM/DD/YY)

of Initial Armed Training

Initial Armed Course Number

Dates (MM/DD/YY) of Continuing Armed Training and Course Number1st Year

Continuing Training

Date (MM/DD/YY)

1st YearContinuing

Training Course Number

2nd YearContinuing

Training Date (MM/DD/YY)

2nd YearContinuing

Training Course Number

License Holder Signature: Date Completed:This form is available on our website https://dps.mn.gov/entity/pdb, under the training area ‐ "Compliance Documents", in WORD and EXCEL formats that will allow you to enter information and save

to your computer. You may also copy this form as needed for your use.

Company Name:

Street Address:

City: State: Zip Code:

Date:

STATE OF MINNESOTABoard of Private Detective and Protective Agent Services 1430 Maryland Avenue East, St. Paul MN 55106

INFORMED CONSENT RENEWAL FORM

PLEASE PRINT FULL NAMELast: First: Middle:

DATE OF BIRTH (MM/DD/YYYY): Sex (M or F):

MAIDEN NAME and/or OTHER NAMES USEDLast: First: Middle:

Last: First: Middle:

APPLICANT ACKNOWLEDGEMENT AND VERIFICATIONPURSUANT TO MN STATUTE 326.3381 I AUTHORIZE THE MINNESOTA BUREAU OF CRIMINAL APPREHENSION TO DISCLOSE ALL CRIMINAL HISTORY RECORD INFORMATION TO THE MINNESOTA BOARD OF PRIVATE DETECTIVES AND PROTECTIVE AGENTS FOR THE PURPOSE OF LICENSURE RENEWAL.

THE EXPIRATION OF THIS AUTHORIZATION SHALL BE ONE YEAR FROM THE DATE OF MY SIGNATURE.

SUBJECT SIGNATURE: DATE:

CERTIFICATE OF COMPLIANCE MINNESOTA WORKERS’ COMPENSATION LAW

Minnesota Statutes §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 presents acceptable evidence of compliance with the workers’ compensation insurance coverage requirement of M.S. Chapter 176. 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 retained in their files.

This information is required by law. 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 or is falsely stated, it may result in a $1,000 penalty assessed against the applicant by the Commissioner of the Department of Labor and Industry.

Insurance Company: (NOT the insurance agent)

Policy Number:

Dates of Coverage: to

-- or --

I have no employees I am self-insured (include permit to self-insure) I have no employees who are covered by the workers’ compensation law

(these include: spouse, parent, children and certain farm employees)

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

Name: Last, First Middle -- Please type or print.

Doing Business As (dba): Business name if different than your name – please type or print.

Business Address: Street Address

City, State, ZIP

Phone: Please include area code.

Signature: Date: