Minnesota Department of Commerce Employee Leasing Company Registration Unit

Employee Leasing Company Registration Form

$100

• Sample Affidavit (if the registrant's Workers Compensation insurance has never been canceled or non renewed)
• Address of each office maintained in the State of Minnesota
• A list by jurisdiction of each and every name that the lessor has operated under in the preceding 5 years including any alternative names and names of predecessors and, if known, successor business entities
• List of each person or entity who owns a 5% or greater interest in the employee leasing business at the time of application and a list of each person who formerly owned a five percent or greater interest in the employee leasing company or its predecessors, or alter egos in the preceding five years
• List of each and every cancellation or non-renewal of workers’ compensation insurance which has been issued to the lessor or any predecessor in the preceding five years. The list shall include the policy or certificate number, name of insurer or other provider of coverage, date of cancellation, and reason for cancellation (if applicable)

Instructions for applying for exemption.

$100

There is no application for exemption. Instead follow the instructions for applying for an exemption.

• List by jurisdiction of every name lessor has operated in the preceding 5 years
• List of each person who owns a 5% or greater interest or formerly owned
• List of every cancellation of workers' compensation insurance in the preceding five years