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Submission #5

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Submission information
Submitted by Anonymous (not verified)
Wed, 2023-03-22 11:21
94.188.207.230
Information About Corporation
Kimberly Owens
2305 E 19th St N lot 109 Newton Ia 50208
Agreements by Individual.
I previously made a written rejection of workers’ compensation or employers’ liability coverage.
I understand that by signing this termination, I will terminate the rejection of coverage that I previously signed and filed.
I also understand that after signing and filing this termination, my status will be the same as if the rejection of coverage had not been made.
I also understand that this termination shall not be effective as to any injury sustained or disease incurred less than one week after it is filed.
Individual Information
Wed, 2023-03-22
Kimberly Owens
Newton
IOWA
United States
Tina Owens
James Chitty
Signed

By typing my full name in this box, I hereby sign this form and, in doing so, swear or affirm that:

  1. The information I have provided is true and correct to the best of my knowledge; 
  2. I am the president, vice president, secretary, or treasurer of the corporation;
  3. I am signing this form in front of the two witnesses I have identified; and
  4. Both of the witnesses are disinterested individuals who are not, formally or informally, affiliated with the corporation.
  5. I understand that this form is a public record open to public inspection under Iowa Code chapter 22 and section 87.22.
Termination by Corporation.
The corporation terminates the prior rejection the employers’ liability coverage.
Corporate Informaion
Kimberly M Owens
Self
Newton
Jasper
United States
Tina Owens
James Chitty
Signed

By typing my full name in this box, I hereby sign this form and swear or affirm that:

  1. The information I have provided is true and correct to the best of my knowledge; 
  2. I am authorized to terminate the rejection of workers’ compensation or employers’ liability coverage on behalf of the corporation.
  3. I am signing this form in front of the two witnesses I have identified; and
  4. Both of the witnesses are disinterested individuals who are not, formally or informally, affiliated with the corporation.
  5. I understand that this form is a public record open to public inspection under Iowa Code chapter 22 and section 87.22.
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