Rejection of Workers' Compensation or Employers' Liability Coverage

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Information about Corporation
Agreements by Individual
Individual Information

By selecting the button labeled "Signed", 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 one of not more than four corporate officers rejecting coverage.
  4. I am signing this form in front of the two witnesses I have identified.
  5. Both of the witnesses are disinterested individuals who are not, formally or informally, affiliated with the corporation.
  6. I understand that this form is a public record open to public inspection under Iowa Code chapter 22 and section 87.22.
Agreement by Corporation.

Check either alternative (1) or (2):

Corporation Information

By selecting the button labeled "Signed", 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 reject or decline to reject employers’ liability coverage on behalf of the corporation.
  3.     I am signing this form in front of the two witnesses I have identified.
  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.