Brown County, MN · Brown County
Minnesota Certificate of Compliance Workers’ Compensation Law
This form documents a business’s workers’ compensation coverage or exemption for applicants seeking a business license or permit in Brown County.
At a glance
- Issued by
- City of Brown County · Brown County, Brown County, Minnesota
- Notarization
- Not required: file this form without a notary.
- Official source
- browncountymn.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
The form records workers’ compensation information for a business license or permit application or renewal. It asks for business and owner details, then asks the applicant to provide insurance company, policy number, and coverage dates, or select an exemption and explain it. Applicants claiming self-insurance are told to include their permit to self-insure; the applicant also certifies the information and signs and dates the form.
Who needs it
Business license or permit applicants in Brown County use this form to provide workers’ compensation coverage information or state an applicable exemption.
How to submit it
Submit it to the county department named on the form; check the county website for current contact details.
About notarization
This document is signed without a notary; the applicant certifies the information is accurate and complete by signing and dating it.
How to submit this form
- 1
Download The Form
Download the Minnesota Certificate of Compliance Workers’ Compensation Law PDF.
- 2
Complete The Form
Enter the business and owner details, then provide coverage information or select and explain an exemption.
- 3
Gather Any Attachment
If claiming self-insurance, include the permit to self-insure.
- 4
Sign And Submit
Certify the information, sign and date the form, and submit it to the county department named on the form.
Frequently asked questions
- What is the workers’ compensation compliance form for?
- It provides workers’ compensation coverage information or an exemption explanation for a business license or permit application or renewal in Brown County.
- What information does the form ask for?
- It asks for business and owner details, insurance company, policy number, and coverage dates, or a selected reason the business is not required to have coverage.
- Do I need a notary for this workers’ compensation form?
- No. The form has no notary block; the applicant certifies the information and signs and dates it. Applicants claiming self-insurance should include their permit to self-insure.
- How do I submit the workers’ compensation form?
- The form does not give submission instructions or contact details. Submit it to the county department named on the form and check the county website for current contact details.