Form 14-0061 - Workers' Compensation Rejection - Dwc, Des Moines, Ia printable pdf download

DIVISION OF WORKERS' COMPENSATION

1000 EAST GRAND AVENUE

DES MOINES, IOWA 50319

14-0061 (6-03)

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________________________________________________________________________________________________________________________________________________

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______________________________________________________________________________________________________________________________________________

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.

Form 14-0061 - Workers' Compensation Rejection - Dwc, Des Moines, Ia

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