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Property Registration Statement and Evidence of Worker's Compensation Joint Application Form

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The Property Registration Statement is designed to gather the information needed before the commissioner may issue a registration certificate under Minnesota Statutes, section 221.0251.

NOTE: Your Form E insurance filing needs to be on file with our office before your application can be processed.

Please read these instructions carefully before completing this application.
(Printing the instructions may be helpful in completing this form.)


Section 1 - Company Name
(The Company Name must match the name listed on your Form E insurance filing.)

(*) Required Fields

*Company Name
DBA (doing business as)
* Street Address
* City, State, and Zip
* Telephone Number



Section 2 - Transportation Type

* Transportation Type -

Hazardous Materials
Hazardous Waste
None of the Above


Section 3 - Company Identifying Numbers

* FEIN (or TIN) Number
MN Business ID Number
USDOT Number
STB (or ICC) Number
EPA Number
Business Type

Corporation
Partnership
Limited Liability Partnership
Sole Proprietorship
Limited Liability Company
Foreign Corporation (*Must Complete Part 5)


Section 4 - Contacts

* Name, title, telephone number of principal person responsible for transportation operations:

* List street address of principal place of business and location where transportation records are kept:

* List city, state, and zip of principal place of business and location where transportation records are kept:

If location listed above is NOT in Minnesota, list location in Minnesota where records will be available for inspection:



Section 5 - Foreign Corporation (This section is required IF foreign corporation was selected as the business type in Section 3.)

State of Incorporation:

Registered agent's name:

Registered agent's business street address:

Registered agent's business city, state, and zip:



Section 6 - Submitter Information

* Applicants Name:

* Applicants Email:

* I am a: (Submitter's title)

Corporate Officer
General Partner
Limited Company Board Member
Sole Proprietor

Date: (MM/DD/YYYY)



Evidence of Worker's Compensation
The Minnesota Department of Transportation is required, by statute, to withhold the issuance or renewal of a license or permit to operate a business in Minnesota until the information required by this form is provided.

* Carrier's Name:

US DOT Number:

Mn/DOT Number:


NOTE:
Either Part A or B must be completed - but not both.
If Part B applies to the applicant, then all files must be completed.

PART A.
The worker’s compensation coverage requirement of Minnesota Statutes, section 176.181, subdivision 2, does not apply to me because (check one):

I am not an "employer" because I do not employ another person to perform a service for-hire.

I have obtained a written order from the commissioner of commerce exempting me from insuring liability for compensation and permitting self-insurance of the liability. I have attached a current copy of my permit to self-insure.

OR

PART B.
The worker’s compensation coverage requirement of Minnesota Statutes, section 176.181, subdivision 2 does apply to me.

Name of Insurance Company:

Policy Number:

Dates of Coverage:

Applicant's Name:

Applicant's Email:

Date:(MM/DD/YYYY)

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