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

Information About Corporation

Name of Corporation: *

Address of Corporation's Home Office: *

Agreements by Individual.

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

Statement 1 Agreement: *

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

Statement 2 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.

Statement 3 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.

Statement 4 Agreement: *

Individual Information

Date: *

Year

Month

Day

Full Name of Individual: *

Email: *

City of Residence: *

County of Residence: *

State of Residence: *

Full Name of Witness 1: *

Full Name of Witness 2: *

Signed

Signing Indication: *

By typing my full name in this box, I hereby sign this form and, in doing so, swear or affirm that:

The information I have provided is true and correct to the best of my knowledge;
I am the president, vice president, secretary, or treasurer of the corporation;
I am signing 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 corporation.
I understand that this form is a public record open to public inspection under Iowa Code chapter 22 and section 87.22.

Termination by Corporation.

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

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

Signed Indication: *

By typing my full name in this box, 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 am signing 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 corporation.
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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