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Submission #14

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Submission information
Submitted by Anonymous (not verified)
Mon, 2023-08-28 08:22
94.188.207.228
Information About Corporation
gibson clover house llc
601 South roosevelt suite 101
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, 2023-08-28
zac gayewski
burlington
Des Moines
IA
Sandra Lee Broeg
Edwin Malone
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
zac r gayewski
president
burlington
Des Moines
IA
Sandra Lee Broeg
Edwin Malone
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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