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Workers Compensation

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

Information About Employer
Agreements by Individual.
Individual Information

 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.
Employer Information

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.
     

Nonelection of Workers' Compensation or Employers' Liability Coverage

Instructions

The Iowa Division of Workers' Compensation (DWC) is no longer accepting the paper version of Form 14-0175, Nonelection of Workers' Compensation or Employers' Liability Coverage.

This online form must be used to make a nonelection of coverage under Iowa Code section 87.22 when the employer has not been issued a workers' compensation or employers' liability policy.

To file the form:

Information About Employer
Agreements by Individual.
Individual Information

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 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; and
  5. Both of the witnesses are disinterested individuals who are not, formally or informally, affiliated with the employer.
  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 Employer.
Employer Information

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 elect or decline to elect employers’ liability coverage on behalf 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 of Rejection of Workers' Compensation or Employers' Liability Coverage

Information About Corporation
Agreements by Individual.
Individual Information

By typing my full name in this box, 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 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 corporation.
  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 Corporation.
Corporate Informaion

By typing my full name in this box, 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 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 corporation.
  5. I understand that this form is a public record open to public inspection under Iowa Code chapter 22 and section 87.22.

Rejection of Workers' Compensation or Employers' Liability Coverage

Instructions

The Iowa Division of Workers' Compensation (DWC) is no longer accepting the paper version of Form 14-0061, Rejection of Workers' Compensation or Employers' Liability Coverage.

This online form must be used to make a rejection of coverage under Iowa Code section 87.22 when the corporation has not been issued a workers' compensation or employers' liability policy.

To file the form:

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.

NOTICE OF DELAY FOR START OF THE WORKERS’ COMPENSATION ELECTRONIC FILING, CASE MANAGEMENT, HEARING SCHEDULING AND EDI SYSTEM (WCES).

The Division of Workers’ Compensation is announcing a delay in the roll-out of WCES, the new electronic filing, case management, hearing scheduling and EDI system for workers’ compensation, WCES.
 
The Division had planned to Go-Live on December 3, 2018.  It has been determined it is not possible to thoroughly test the system before December 3, 2018. The Division was advised to delay the Go-Live date until we can be confident WCES has been thoroughly tested.