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  1. Termination of Nonelection of Workers' Compensation or Employers' Liability Coverage
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Submission #10

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Submission information
Submitted by Anonymous (not verified)
Mon, 2023-02-06 17:01
142.202.101.9
Information About Employer
Polhamus Transfer LLC
Limited Liability Company
500 N Elm Street Mechanicsville Ia 52306-0027
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
Mon, 2023-02-06
Matthew W. Polhamus
Mechanicsville
Cedar
Iowa
Lorraine K Polhamus
Ryan S Steinberg
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
Matthew W. Polhamus
Self
Mechanicsville
Cedar
Iowa
Lorraine K Polhamus
Ryan S Steinberg
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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