Diane London
dlondon@gmail.com
Owner
Ft Pierre
Stanley
Sd
James
Skyla
Signed
By selecting the "Signed" button above, 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 signed 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 employer.
- I understand that this form is a public record open to public inspection under Iowa Code chapter 22 and section 87.22.