Nonelection of Workers' Compensation or Employers' Liability Coverage | Iowa Workers' Compensation

Official State of Iowa Website Here is how you know

Agencies A-Z Programs & Services

Primary tabs

Secondary tabs

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 Blank	0
User entered value	1944
Average submission length in words (ex blanks)	3.10

Type of Entity:

Proprietorship	849
Limited Liability Company	1010
Limited Liability Partnership	28
Partnership	57

Date:

Left Blank	0
User entered value	1944

Full Name of Individual:

Left Blank	0
User entered value	1944
Average submission length in words (ex blanks)	2.40

Email:

Left Blank	0
User entered value	1944
Average submission length in words (ex blanks)	3.17

City of Residence:

Left Blank	0
User entered value	1944
Average submission length in words (ex blanks)	1.42

County of Residence:

Left Blank	0
User entered value	1944
Average submission length in words (ex blanks)	1.10

State of Residence:

Left Blank	0
User entered value	1944
Average submission length in words (ex blanks)	1.15

Full Name of Witness 1:

Left Blank	0
User entered value	1944
Average submission length in words (ex blanks)	2.18

Full Name of Witness 2:

Left Blank	0
User entered value	1944
Average submission length in words (ex blanks)	2.16

Signing Indication:

Signed	1944

Check either alternative (1) or (2):

(1) The employer does not elect the employers’ liability coverage.	1856
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	88

Full Name of Authorized Agent:

Left Blank	0
User entered value	1944
Average submission length in words (ex blanks)	2.41

Email of Authorized Agent:

Left Blank	0
User entered value	1944
Average submission length in words (ex blanks)	3.17

Relationship to Employer of Authorized Agent:

Left Blank	0
User entered value	1944
Average submission length in words (ex blanks)	1.25

City of Residence:

Left Blank	0
User entered value	1944
Average submission length in words (ex blanks)	1.41

County of Residence:

Left Blank	0
User entered value	1944
Average submission length in words (ex blanks)	1.09

State of Residence:

Left Blank	0
User entered value	1944
Average submission length in words (ex blanks)	1.14

Full Name of Witness No. 1:

Left Blank	0
User entered value	1944
Average submission length in words (ex blanks)	2.18

Full Name of Witness No. 2:

Left Blank	0
User entered value	1944
Average submission length in words (ex blanks)	2.16

Signing Indication:

Signed	1944

Add analysis components

Include all components
Information About Employer
Name of Employer:
Type of Entity:
Address of Employer's Home Office:
Agreements by Individual.
Statement 1 Agreement:
Statement 2 Agreement:
Statement 3 Agreement:
Understanding Confirmation:
Check Either Alternative (1) or (2):
Individual Information
Date:
Full Name of Individual:
Email:
City of Residence:
County of Residence:
State of Residence:
Full Name of Witness 1:
Full Name of Witness 2:
Signing Indication:
Signed Agreement:
Agreement by Employer.
Check either alternative (1) or (2):
Employer Information
Full Name of Authorized Agent:
Email of Authorized Agent:
Relationship to Employer of Authorized Agent:
City of Residence:
County of Residence:
State of Residence:
Full Name of Witness No. 1:
Full Name of Witness No. 2:
Signing Indication:
Form 3 Lower Signed Agreement:

Leave this field blank