Follow the steps to successfully complete the LIC 04 form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter your business telephone number, fax number, and business name. If your business structure is a sole proprietorship or partnership, use the names of the individuals (e.g., John Doe or John Doe and Jane Doe). For other structures, use the legal business entity name.
3. Fill in the DBA (doing business as) information if applicable, followed by the business address. Ensure that you provide a physical street address; P.O. boxes are not acceptable.
4. Complete the city, county, state, and zip code fields related to your business address.
5. Provide your email address for correspondence.
6. Select either number 1 or number 2 to provide workers’ compensation insurance policy information or state your reason for exemption. For number 1, include the insurance company name, policy number, NAIC number, effective date, and expiration date.
7. If selecting number 2, indicate your reason for exemption by marking the appropriate box. If you have employees who are not covered, provide an explanation in the space provided.
8. Certify the accuracy and completeness of the information provided by signing and dating the form. If signing on behalf of a business, ensure you are authorized to do so.
9. Review all filled fields for accuracy. Once completed, you can save changes, download the form, print it, or share it as needed.

Complete your LIC 04 form online today to ensure compliance with Minnesota Workers’ Compensation Law.