Do I need a notary for this workers’ compensation certification?

No. The document has a signature and date line, not a notary block. The signer signs and dates it; applicants claiming self-insured status must include their permit to self-insure.

How do I submit the certification?

Submit it to the county department named on the form; check the county website for current contact details. The document does not provide a submission address or email.

What information does the certification ask for?

It asks for the insurance company name, policy number, and coverage dates, or a reason coverage is not required. It also requests applicant and business contact information, signature, and date.

What should I include if I am self-insured?

The form lists self-insured status as a reason coverage may not be required and says to include the permit to self-insure.

Isanti County, MN · Isanti County

No notary required

Certification of Compliance With Minnesota Workers’ Compensation Law

This certification provides workers’ compensation insurance or exemption information for a business applicant seeking a county license or permit.

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: Oct 5, 2026
Machine-readable: JSON record · about the forms index

What this form is

This form certifies workers’ compensation compliance for an applicant seeking a business license or permit. It asks for the insurance company, policy number, coverage dates, or the reason coverage is not required; self-insured applicants must include their permit to self-insure. The licensing agency collects and retains this information, which the document says is required before a license or permit can be issued or renewed.

Who needs it

Business applicants seeking a license or permit must complete this certification with coverage details or a reason workers’ compensation coverage is not required.

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 and dated without a notary; applicants claiming self-insured status must include their permit to self-insure.

How to submit this form

1
Download the Form
Download the Certification of Compliance form for Isanti County.
2
Complete the Certification
Enter insurance details or the reason coverage is not required, along with the requested applicant and business information.
3
Gather Required Attachment
If you are self-insured, include your permit to self-insure.
4
Submit to the County
Submit the completed form to the county department named on it; check the county website for current contact details.

Frequently asked questions

Do I need a notary for this workers’ compensation certification?: No. The document has a signature and date line, not a notary block. The signer signs and dates it; applicants claiming self-insured status must include their permit to self-insure.
How do I submit the certification?: Submit it to the county department named on the form; check the county website for current contact details. The document does not provide a submission address or email.
What information does the certification ask for?: It asks for the insurance company name, policy number, and coverage dates, or a reason coverage is not required. It also requests applicant and business contact information, signature, and date.
What should I include if I am self-insured?: The form lists self-insured status as a reason coverage may not be required and says to include the permit to self-insure.

Need something notarized?

This Certification of Compliance With Minnesota Workers’ Compensation Law doesn’t need a notary, but if you have another Isanti County form that does, a commissioned online notary can help.