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|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
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
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
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.