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  1. Termination of Rejection of Workers' Compensation or Employers' Liability Coverage
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  3. Submission #6

Submission #6

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Submission information
Submitted by Anonymous (not verified)
Wed, 2023-03-22 11:23
94.188.207.224
Information About Corporation
TRACY SCALES
1920 FRANKLIN AVE
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
Mon, 2022-03-21
TRACY SCALES
DES MOINES
POLK
IOWA
TINA OWNES
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
TRACY SCALES
self
DES MOINES
POLK
DES MOINES
TINA OWNES
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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