Rejection of Workers' Compensation or Employers' Liability Coverage

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Instructions

The Iowa Division of Workers' Compensation (DWC) is no longer accepting the paper version of Form 14-0061, Rejection of Workers' Compensation or Employers' Liability Coverage.

This online form must be used to make a rejection of coverage under Iowa Code section 87.22 when the corporation has not been issued a workers' compensation or employers' liability policy.

To file the form:

  1. Provide all requested information.
  2. The corporate officer and authorized representative of the corporation must sign the form by selecting the "Signed" in front of two disinterested witnesses, who have no formal or informal affiliation with the corporation.
  3. You must click the "Submit" button to file the completed and signed form with DWC.

After you complete, sign, and submit the form, you will receive a verification email at the address(es) provided with the information you provided on the form to verify your submission of the form.

The information you provided will also be shown on the public list of persons who have made a rejection of coverage. 

For resources relating to rejections of coverage, click here.

Rejection of Workers' Compensation or Employers' Liability Coverage Under Iowa Code Section 87.22 (Form 14-0061)

Information about Corporation
Agreements by Individual
Individual Information

By selecting the button labeled "Signed", 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 the president, vice president, secretary, or treasurer of the corporation.
  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.
  5. Both of the witnesses are disinterested individuals who are not, formally or informally, affiliated with the corporation.
  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 Corporation.

Check either alternative (1) or (2):

Corporation Information

By selecting the button labeled "Signed", 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 reject or decline to reject employers’ liability coverage on behalf of the corporation.
  3.     I am signing this form in front of the two witnesses I have identified.
  4.     Both of the witnesses are disinterested individuals who are not, formally or informally, affiliated with the corporation.
  5.     I understand that this form is a public record open to public inspection under Iowa Code chapter 22 and section 87.22.