Isanti County, MN · Isanti County
Certificate of Compliance Minnesota Workers’ Compensation Law
Businesses applying for a license or permit use this form to provide information about their workers’ compensation coverage or explain why coverage is not required.
At a glance
- Issued by
- City of Isanti County · Isanti County, Isanti County, Minnesota
- Notarization
- Not required: file this form without a notary.
- Official source
- isanticountymn.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
The business license applicant completes this certificate to provide evidence of compliance with workers’ compensation insurance coverage requirements. It asks for business and contact details, then requires the applicant to report insurance policy information or select an exemption and explain it when applicable. If the information provided changes, the applicant must resubmit the form to the authority issuing the license.
Who needs it
A business license applicant must complete this form and provide it to the authority issuing the license or permit.
How to submit it
Submit the completed form to the authority issuing your license or permit. If you are self-insured, attach a copy of the authorization to self-insure.
About notarization
This form is signed and dated without a notary; the signer certifies that the information is accurate and complete.
How to submit this form
- 1
Download the Form
Download the Certificate of Compliance Minnesota Workers’ Compensation Law PDF.
- 2
Complete the Business Information
Enter the business and contact details, then provide workers’ compensation policy information or select and explain an applicable exemption.
- 3
Gather Any Required Attachment
If you are self-insured, attach a copy of the authorization to self-insure.
- 4
Sign and Submit
Print your name, sign, and date the form, then submit it to the authority issuing your license or permit.
Frequently asked questions
- Who completes the workers’ compensation compliance form?
- The form says it must be completed by the business license applicant. It asks for business details and information about workers’ compensation coverage or an applicable exemption.
- How do I submit the workers’ compensation compliance form?
- Submit the completed form to the authority issuing your license or permit. If you are self-insured, attach a copy of the authorization to self-insure.
- Do I need a notary for the workers’ compensation compliance form?
- No. This form is signed and dated without a notary; the signer certifies that the information is accurate and complete.
- What if the information on my form changes?
- The form says you must resubmit it to the authority issuing your license if any of the information you provided changes.