Nonelection of Workers' Compensation or Employers' Liability Coverage

Information About Employer

Name of Employer: *

Type of Entity: *

Proprietorship

Limited Liability Company

Limited Liability Partnership

Partnership

Address of Employer's Home Office: *

Agreements by Individual.

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.

Statement 1 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.

Statement 2 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.

Statement 3 Agreement: *

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.

Understanding Confirmation: *

Check Either Alternative (1) or (2): *

(1) I am not electing the employers’ liability coverage.

(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.

Individual Information

Date: *

Year

Month

Day

Full Name of Individual: *

Email: *

City of Residence: *

County of Residence: *

State of Residence: *

Full Name of Witness 1: *

Full Name of Witness 2: *

Signed

Signing Indication: *

By selecting the "Signed" button above, I hereby sign this form and, in doing so, swear or affirm that:

The information I have provided is true and correct to the best of my knowledge;
I am a proprietor, limited liability company member, limited liability partner, or partner of the employer;
I am one of not more than four corporate officers rejecting coverage;
I am signing this form in front of the two witnesses I have identified; and
Both of the witnesses are disinterested individuals who are not, formally or informally, affiliated with the employer.
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.

Check either alternative (1) or (2): *

(1) The employer does not elect the employers’ liability coverage.

(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.

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: *

Signed

Signing Indication: *

By selecting the "Signed" button above, I hereby sign this form and swear or affirm that:

The information I have provided is true and correct to the best of my knowledge;
I am authorized to elect or decline to elect employers’ liability coverage on behalf of the employer.
I am signing this form in front of the two witnesses I have identified; and
Both of the witnesses are disinterested individuals who are not, formally or informally, affiliated with the employer.
I understand that this form is a public record open to public inspection under Iowa Code chapter 22 and section 87.22.

Leave this field blank

Nonelection of Workers' Compensation or Employers' Liability Coverage

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Instructions

Nonelection of Workers' Compensation or Employers' Liability Coverage Under Iowa Code Section 87.22 (Form 14-0175)