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  1. Termination of Nonelection of Workers' Compensation or Employers' Liability Coverage
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Submission #9

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Submission information
Submitted by Anonymous (not verified)
Tue, 2022-09-13 15:01
192.30.185.233
Information About Employer
Silverio De Los Santos Gonzalez
Proprietorship
2010 Virginia Street Sioux City, IA 51104
Agreements by Individual.
I previously made a nonelection of workers’ compensation or employers’ liability coverage.
I understand that by signing this termination, I will terminate the nonelection of coverage.
I also understand that after signing and filing this termination, my status will be the same as if the nonelection 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
Tue, 2022-09-13
Silverio De Los Santos Gonzalez
Sioux City
Woodbury
Iowa
Jeffrey H. McClintock
Timothy J McClintock
Signed

 By selecting the "Signed" button above, 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 a proprietor, limited liability company member, limited liability partner, or partner of the employer;
  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 employer.
  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 Employer.
The employer terminates the prior nonelection the employers’ liability coverage.
Employer Information
Jeffrey H McClintock
agent
sioux city
ia
ia
Jeffrey H. McClintock
Timothy J. Mcclintock
Signed

By selecting the "Signed" button above, 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 signed 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 employer.
  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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