Nonelection of Workers' Compensation or Employers' Liability Coverage

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Information About Employer
Agreements by Individual.
Individual Information

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

  1. The information I have provided is true and correct to the best of my knowledge; 
  2. I am a proprietor, limited liability company member, limited liability partner, or partner of the employer;
  3. I am one of not more than four corporate officers rejecting coverage;
  4. I am signing this form in front of the two witnesses I have identified; and
  5. Both of the witnesses are disinterested individuals who are not, formally or informally, affiliated with the employer.
  6. 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.
Employer Information

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

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