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Nonelection 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 Employer:

Left Blank0
User entered value2227
Average submission length in words (ex blanks)3.10

Type of Entity:

Proprietorship981
Limited Liability Company1146
Limited Liability Partnership36
Partnership64

Address of Employer's Home Office:

Left Blank0
User entered value2227
Average submission length in words (ex blanks)4.38

Statement 1 Agreement:

I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.2227

Statement 2 Agreement:

I understand that my nonelection 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 employment with the employer.2227

Statement 3 Agreement:

I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.2227

Understanding Confirmation:

I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.2227

Check Either Alternative (1) or (2):

(1) I am not electing the employers’ liability coverage.2140
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.87

Date:

Left Blank0
User entered value2227

Full Name of Individual:

Left Blank0
User entered value2227
Average submission length in words (ex blanks)2.41

City of Residence:

Left Blank0
User entered value2227
Average submission length in words (ex blanks)1.42

County of Residence:

Left Blank0
User entered value2227
Average submission length in words (ex blanks)1.10

State of Residence:

Left Blank0
User entered value2227
Average submission length in words (ex blanks)1.15

Full Name of Witness 1:

Left Blank0
User entered value2227
Average submission length in words (ex blanks)2.18

Full Name of Witness 2:

Left Blank0
User entered value2227
Average submission length in words (ex blanks)2.16

Signing Indication:

Signed2227

Check either alternative (1) or (2):

(1) The employer does not elect the employers’ liability coverage.2128
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.99

Full Name of Authorized Agent:

Left Blank0
User entered value2227
Average submission length in words (ex blanks)2.41

Relationship to Employer of Authorized Agent:

Left Blank0
User entered value2227
Average submission length in words (ex blanks)1.25

City of Residence:

Left Blank0
User entered value2227
Average submission length in words (ex blanks)1.41

County of Residence:

Left Blank0
User entered value2227
Average submission length in words (ex blanks)1.10

State of Residence:

Left Blank0
User entered value2227
Average submission length in words (ex blanks)1.14

Full Name of Witness No. 1:

Left Blank0
User entered value2227
Average submission length in words (ex blanks)2.18

Full Name of Witness No. 2:

Left Blank0
User entered value2227
Average submission length in words (ex blanks)2.16

Signing Indication:

Signed2227