Olmsted County, MN · Olmsted County
Certificate of Compliance Minnesota Workers’ Compensation Law
Olmsted County business license applicants complete this certificate to provide information about workers’ compensation coverage or an exemption.
At a glance
- Issued by
- City of Olmsted County · Olmsted County, Olmsted County, Minnesota
- Notarization
- Not required: file this form without a notary.
- Official source
- olmstedcounty.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
This certificate provides Olmsted County with workers’ compensation coverage information from a business license applicant. Applicants must complete it before the county issues or renews a business license or permit to operate a business in Minnesota. The form asks for business and applicant details, coverage or exemption information, and the applicant’s printed name, signature, title, and date.
Who needs it
A business license applicant must complete this certificate and resubmit it if any information provided on the form changes.
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 form is signed and dated without a notary; self-insured applicants attach authorization to self-insure from the Minnesota Department of Commerce.
How to submit this form
- 1
Download the Certificate
Download the Certificate of Compliance Minnesota Workers’ Compensation Law PDF.
- 2
Complete the Business Details
Provide the requested applicant and business information, including a physical street address.
- 3
Provide Coverage or Exemption Information
Complete the section that applies to your workers’ compensation coverage or explain why coverage is not required.
- 4
Gather Any Required Attachment
If self-insured, attach a copy of the authorization to self-insure from the Minnesota Department of Commerce.
- 5
Sign and Submit
Print your name, sign and date the form, then submit it to the county department named on the form.
Frequently asked questions
- Do I need a notary for the Workers’ Compensation Compliance Certificate?
- No. The applicant signs and dates the form without a notary. Applicants who are self-insured must attach their authorization to self-insure from the Minnesota Department of Commerce.
- Who must complete this certificate?
- The form says it must be completed by the business license applicant. It asks for business details and information about workers’ compensation coverage or the reason coverage is not required.
- How do I submit the certificate?
- Submit it to the county department named on the form; check the county website for current contact details.
- What if the information on my certificate changes?
- The form instructs applicants to resubmit it to the authority issuing the license if any information they provided changes.