Nonelection of Workers' Compensation or Employers' Liability Coverage
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 | 2178 |
| Average submission length in words (ex blanks) | 3.10 |
Type of Entity:
| Proprietorship | 959 |
| Limited Liability Company | 1119 |
| Limited Liability Partnership | 36 |
| Partnership | 64 |
Address of Employer's Home Office:
| Left Blank | 0 |
| User entered value | 2178 |
| 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. | 2178 |
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. | 2178 |
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. | 2178 |
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. | 2178 |
Check Either Alternative (1) or (2):
| (1) I am not electing the employers’ liability coverage. | 2092 |
| (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. | 86 |
Date:
| Left Blank | 0 |
| User entered value | 2178 |
Full Name of Individual:
| Left Blank | 0 |
| User entered value | 2178 |
| Average submission length in words (ex blanks) | 2.41 |
Email:
| Left Blank | 0 |
| User entered value | 2178 |
| Average submission length in words (ex blanks) | 3.17 |
City of Residence:
| Left Blank | 0 |
| User entered value | 2178 |
| Average submission length in words (ex blanks) | 1.43 |
County of Residence:
| Left Blank | 0 |
| User entered value | 2178 |
| Average submission length in words (ex blanks) | 1.10 |
State of Residence:
| Left Blank | 0 |
| User entered value | 2178 |
| Average submission length in words (ex blanks) | 1.15 |
Full Name of Witness 1:
| Left Blank | 0 |
| User entered value | 2178 |
| Average submission length in words (ex blanks) | 2.19 |
Full Name of Witness 2:
| Left Blank | 0 |
| User entered value | 2178 |
| Average submission length in words (ex blanks) | 2.16 |
Signing Indication:
| Signed | 2178 |
Check either alternative (1) or (2):
| (1) The employer does not elect the employers’ liability coverage. | 2080 |
| (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. | 98 |
Full Name of Authorized Agent:
| Left Blank | 0 |
| User entered value | 2178 |
| Average submission length in words (ex blanks) | 2.41 |
Email of Authorized Agent:
| Left Blank | 0 |
| User entered value | 2178 |
| Average submission length in words (ex blanks) | 3.17 |
Relationship to Employer of Authorized Agent:
| Left Blank | 0 |
| User entered value | 2178 |
| Average submission length in words (ex blanks) | 1.24 |
City of Residence:
| Left Blank | 0 |
| User entered value | 2178 |
| Average submission length in words (ex blanks) | 1.41 |
County of Residence:
| Left Blank | 0 |
| User entered value | 2178 |
| Average submission length in words (ex blanks) | 1.10 |
State of Residence:
| Left Blank | 0 |
| User entered value | 2178 |
| Average submission length in words (ex blanks) | 1.14 |
Full Name of Witness No. 1:
| Left Blank | 0 |
| User entered value | 2178 |
| Average submission length in words (ex blanks) | 2.18 |
Full Name of Witness No. 2:
| Left Blank | 0 |
| User entered value | 2178 |
| Average submission length in words (ex blanks) | 2.16 |
Signing Indication:
| Signed | 2178 |