James Chitty
techsupport@smartind.com
self
colo
story
iowa
Robin Russo
Tina Owens
Signed
By typing my full name in this box, I hereby sign this form and swear or affirm that:
- The information I have provided is true and correct to the best of my knowledge;
- I am authorized to terminate the rejection of workers’ compensation or employers’ liability coverage on behalf of the corporation.
- I am signing this form in front of the two witnesses I have identified; and
- Both of the witnesses are disinterested individuals who are not, formally or informally, affiliated with the corporation.
- I understand that this form is a public record open to public inspection under Iowa Code chapter 22 and section 87.22.