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Employer Information
Employer Name
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Entity Type
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Proprietorship
Limited Liability Company
Limited Liability Partnership
Partnership
Employer Address
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Attestation by Individual
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Attestation by Individual
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 agreeing to these statements 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.
Attestation by Individual
I choose to terminate my previous non-election of coverage. I understand that by filing this termination, I will terminate the nonelection of coverage. I understand that filing this termination, my status will be the same as if the nonelection of coverage had not been made. I also understand that this termination will not be effective as to any injury sustained or disease incurred less than one week after it is filed.
Individual Information
Date
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Full Name of Individual
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Email
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City of Residence
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County of Residence
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State of Residence
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Full Name of Witness 1
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Full Name of Witness 2
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I agree
I agree
No
I agree
Yes
Agreement by Employer.
Check either option:
*
Check either option:
The employer does not elect the employers’ liability of coverage.
Check either option:
The employer terminates the prior nonelection of the employers’ liability coverage.
Employer Information
Authorized Agent
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Authorized Agent Email
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Relationship to Employer
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Authorized Agent City
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Authorized Agent County
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Authorized Agent State
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Full Name of Witness No. 1
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Full Name of Witness No. 2
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*
I agree
I agree
No
I agree
Yes
