ࡱ> /2._  bjbjjj =,b,b;``8.$$$$$      $!D"D``$$Y~~~j`8$$~~~~$`mp<R~ o0~"B"~"~~DD"B &:  WORKERS COMPENSATION EXEMPTION FORM This is to inform you that I do not hire any employees other than my family; therefore, based on Minn.Stat.176.041, Subd. 1, I am not required to have workers compensation insurance. In the event of an injury while working under a State of Minnesota Contract I/we agree to waive my/our right to sue the State of Minnesota, its employees, or Officers. I certify that I will always remain in compliance with Minn. Statutes pertaining to workers' compensation insurance coverage. I understand that my employees and agents will not be considered State employees. Any claims that may arise under the Minnesota Workers' Compensation Act on behalf of these employees or agents, and any claims made by any third party as a consequence of any act or omission on the part of these employees or agents, are in no way the State's obligation or responsibility. Name of Company Company Address Date Signature Title     Workers Compensation Form (08/09) Appendix D Forms  !&tuv   򱣱yyyyh,CJOJQJ^JaJh2ACJOJQJ^JaJhCJOJQJ^JaJh<CJOJQJ^JaJhoCJOJQJ^JaJ ho5CJOJQJ\^JaJ h<5CJOJQJ\^JaJ huN@5CJOJQJ\^JaJhuN@CJOJQJ^JaJ'&'()   gd,$a$       ƵΊhh/hB*phh2Ah2ACJOJQJ^JaJhnJCJOJQJ^JaJ hh2ACJOJQJ^JaJh^hnJh/1jh/1Uh,CJOJQJ^JaJ.jhCJOJQJU^JaJmHnHu!          gd,;0P:p/ =!"#$%" Dps2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH L`L Normal1$7$8$H$CJ_HaJmH sH tH DA D Default Paragraph FontRiR  Table Normal4 l4a (k (No List <& < Footnote Referencevv  Table Grid7:V01$7$8$H$4@4 Header  !4 @"4 Footer  !H2H o Balloon TextCJOJQJ^JaJN/AN oBalloon Text CharCJOJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vc:E3v@P~Ds |w<  68:=      @ @H 0(  (  P   "? B S  ?$t !tv !tv /1uN@?,A2AYIT4nZXcN y\x|5Q<joj9|^lb,/drbnJ@@UnknownG.[x Times New Roman5Symbol3. .Cx Arial5. .[`)TahomaA$BCambria Math" hffs;ئ77! xxr3Q ?uN@2!xx STATE OF MINNESOTAJoseph Jameson Zackary Seitz Oh+'0 , L X d p|STATE OF MINNESOTAJoseph JamesonNormalZackary Seitz2Microsoft Office Word@F#@k@h@h7 ՜.+,0  hp  Ann Jameson, Inc. STATE OF MINNESOTA Title  !"#$%'()*+,-014Root Entry F`p3@1Table "WordDocument =SummaryInformation(DocumentSummaryInformation8&MsoDataStorep`mpRBYIYSKSTBNGQ==2p`mpItem PropertiesUCompObj r   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q