Dakota County, MN · Dakota County
Certificate of Compliance With Minnesota Worker's Compensation
This form lets a business applicant provide workers' compensation coverage details or certify why the business is excluded from the requirement.
At a glance
- Issued by
- City of Dakota County · Dakota County, Dakota County, Minnesota
- Notarization
- Not required: file this form without a notary.
- Official source
- dakotacountymn.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
Business license and permit applicants use this form to provide evidence of workers' compensation coverage or explain why the business is not required to have it. It asks for the business name, federal tax ID, insurance company, policy or self-insurance permit number, coverage dates, and the applicant's Social Security number. The signer certifies that the information is true and correct.
Who needs it
A business applying for or renewing a license or permit should provide this information to the licensing agency as part of its application.
How to submit it
Submit it to the county office named on the form; check the county website for current contact details.
About notarization
This document is signed without a notary; the signer just signs and provides the requested information.
How to submit this form
- 1
Download the Form
Download the workers' compensation compliance form.
- 2
Complete the Business Information
Enter the business name, federal tax ID, and requested insurance or self-insurance details.
- 3
State an Exclusion if Applicable
If the business is not required to have workers' compensation coverage, select the applicable reason or specify another reason.
- 4
Sign and Submit
Sign the certification and submit the form to the county office named on it.
Frequently asked questions
- What does the workers' compensation compliance form ask for?
- It asks for the business name, federal tax ID, insurer, policy or self-insurance permit number, coverage dates, and the applicant's Social Security number. Applicants may instead state why the business is excluded.
- Who should complete this form?
- A business applying for or renewing a license or permit should provide the requested workers' compensation information or certify why the business is not required to have coverage.
- Do I need a notary for the workers' compensation compliance form?
- No. This document is signed without a notary; the signer just signs and provides the requested information.
- How do I submit the workers' compensation compliance form?
- Submit it to the county office named on the form. The document does not provide submission contact details, so check the county website for current information.