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Rejection of Workers' Compensation or Employers' Liability Coverage

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This page shows analysis of submitted data, such as the number of submissions per component value, calculations, and averages. Additional components may be added under the "Add analysis components" fieldset.

Name of Corporation:

Left Blank0
User entered value920
Average submission length in words (ex blanks)3.57

Statement 1 Agreement:

I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.920

Statement 2 Agreement:

I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation.920

Statement 3 Agreement:

I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation.920

Statement Agreement:

I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation.920

Check Either Alternative (1) or (2):

(1) I reject the employers’ liability coverage.890
(2) I decline to reject the employer’s liability coverage.30

Full Name of Individual:

Left Blank0
User entered value920
Average submission length in words (ex blanks)2.40

Signing Agreement:

Signed920

Alternative Selection:

(1) The corporation rejects the employers’ liability coverage.862
(2) The corporation declines to reject the employers’ liability coverage.58

Signing Indication:

Signed920