The 14 0061 form plays a pivotal role for corporate officers in Iowa, addressing the specific provisions under Iowa Code section 87.22 that allow certain corporate officers to opt out of workers' compensation or employers' liability coverage. Designed to enable the president, vice president, secretary, and treasurer of corporations—excluding those of family farm corporations, with a cap of four officers—to voluntarily exclude themselves from the said coverage, it necessitates a conscious and voluntary rejection by these officers. This is executed through signing a written rejection that is either attached to the workers’ compensation or employers’ liability policy or, in the absence of such a policy, filed with the workers' compensation commissioner after being witnessed by two disinterested individuals not affiliated with the corporation. The form explicitly clarifies that this rejection does not equate to waiving other legal rights or remedies that may be pursued in civil actions related to personal injuries incurred in the course of employment. Officers are provided with a choice to reject employers’ liability coverage specifically, with instructions to check one of two alternatives to indicate their decision. The document further outlines the process for the termination of this rejection, requiring a written notice of termination to also be duly witnessed and filed with the commissioner, emphasizing that such rejections cannot be mandated as a condition of employment. Needless to say, this form embodies a critical legal instrument for corporate officers in Iowa, delineating the steps and understanding necessary to waive statutory workers' compensation or employers’ liability coverage in a structured and legally recognized manner, while maintaining the integrity of their rights to pursue other forms of legal redress.
| Question | Answer |
|---|---|
| Form Name | Filliable Form 14 0061 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | fillable iowa workforce form 14 0175, iowa form 140061, declines, ia form 14 0061 |
DIVISION OF WORKERS' COMPENSATION 1000 EAST GRAND AVENUE
DES MOINES, IOWA 50319
CORPORATION NAME:_______________________________________________________________________________________
ADDRESS (Include Street, City, State and Zip Code)____________________________________________________________
____________________________________________________________________________________
CORPORATE OFFICER EXCLUSION FROM WORKERS’ COMPENSATION OR EMPLOYERS’ LIABILITY COVERAGE
Iowa Code section 87.22.
The president, vice president, secretary and treasurer of a corporation other than a family farm corporation, but not to exceed four officers per corporation may exclude themselves from workers’ compensation coverage under chapters 85, 85A and 85B by knowingly and voluntarily rejecting workers’ compensation coverage by signing and attaching to the workers’ compensation or employers’ liability policy, a written rejection, or if such a policy is not issued, by signing a written rejection which is witnessed by two disinterested individuals who are not, formally or informally, affiliated with the corporation and which is filed by the corporation with the workers' compensation commissioner, in substantially the following form:
REJECTION OF WORKERS’ COMPENSATION OR EMPLOYERS’ LIABILITY COVERAGE
I understand that by signing this statement, I reject the coverage of chapters 85, 85A and 85B of the Code of Iowa relating to workers’ compensation.
I understand that my rejection 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 my employment with the corporation.
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. Check either alternative (1) or (2):
(1)I reject the employers’ liability coverage.
(2)I decline to reject the employers' liability coverage.
NAME (TYPED AND SIGNED):_________________________________________________________________________________________________________________
CORPORATE OFFICE_______________________________________________________________________________DATE ___________________________________
CITY, COUNTY, STATE OF
RESIDENCE__________________________________________________________________________________________________________________
WITNESS_________________________________________________________________________________________________________________________________________
__
WITNESS_________________________________________________________________________________________________________________________________________
__
I also understand that the signing of this statement and checking of alternative (1) below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. Check either alternative (1) or (2):
(1)The corporation rejects the employers’ liability coverage.
(2)The corporation declines to reject the employers’ liability coverage.
NAME (TYPED AND SIGNED) _____________________________________________________________________________________________________________
RELATIONSHIP TO CORPORATION______________________________________________________________DATE __________________________________
CITY, COUNTY, STATE OF
RESIDENCE___________________________________________________________________________________________________________________
WITNESS_______________________________________________________________________________________________________________________
WITNESS_______________________________________________________________________________________________________________________
The rejection of workers’ compensation coverage is not enforceable if it is required as a condition of employment. A corporate officer who signs a written rejection filed with the workers' compensation commissioner may terminate the rejection by signing a written notice of termination which is witnessed by two disinterested individuals, who are not, formally or informally, affiliated with the corporation and which is filed by the corporation with the workers' compensation commissioner.
TO BE ATTACHED TO THE CORPORATION WORKERS’ COMPENSATION OR EMPLOYERS’ LIABILITY INSURANCE POLICY. IF NO POLICY IS IN EFFECT THEN TO BE MAILED TO IOWA WORKERS' COMPENSATION DIVISION, 1000 EAST GRAND AVENUE, DES MOINES, IOWA 50319
THE INFORMATION PROVIDED WILL BE OPEN FOR PUBLIC INSPECTION UNDER IOWA CODE §22.11.
