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):]
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):]
Signed .........................................................
Relationship to Corporation ..............................................
Date ...........................................
City, County, State of Residence ..................................................
Witness ................................................................................
Witness ................................................................................
NONELECTION OF WORKERS' COMPENSATION OR EMPLOYERS' LIABILITY COVERAGE
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.
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 my employment with the employer.
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. [Check either alternative (1) or (2):]
Signed .........................................................
Employer's 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 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. [Check either alternative (1) or (2):]
Signed .........................................................
Relationship to Employer ..................................................
Date ...........................................
City, County, State of Residence ..................................................
Witness ................................................................................
Witness ................................................................................
Iowa Code § 87.22
83 Acts, ch 36, §5, 7, 8; 97 Acts, ch 186, §1; 98 Acts, ch 1061, §11; 2008 Acts, ch 1031, §28; 2015 Acts, ch 47, §1
Referred to in §85.1, 517.6