Termination of Rejection of Workers' Compensation or Employers' Liability Coverage

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Statement 1 Agreement:

I previously made a written rejection of workers’ compensation or employers’ liability coverage.	12

Statement 2 Agreement:

I understand that by signing this termination, I will terminate the rejection of coverage that I previously signed and filed.	12

Statement 3 Agreement:

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.	12

Statement 4 Agreement:

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.	12

Signing Indication:

Signed	12

Termination Agreement:

The corporation terminates the prior rejection the employers’ liability coverage.	12

Signed Indication:

Signed	12

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Information About Corporation
Name of Corporation:
Address of Corporation's Home Office:
Agreements by Individual.
Statement 1 Agreement:
Statement 2 Agreement:
Statement 3 Agreement:
Statement 4 Agreement:
Individual Information
Date:
Full Name of Individual:
Email:
City of Residence:
County of Residence:
State of Residence:
Full Name of Witness 1:
Full Name of Witness 2:
Signing Indication:
Signed Agreement form 2:
Termination by Corporation.
Termination Agreement:
Corporate Informaion
Full Name of Authorized Agent:
Email:
Relationship to Corporation:
City of Residence:
County of Residence:
State of Residence:
Full Name of Witness No. 1:
Full Name of Witness No. 2:
Signed Indication:
Form 2 Lower Signed Agreement:

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