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Employer Information

Employer Name

Entity Type

Employer Address

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.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

Full Name of Individual

City of Residence

County of Residence

State of Residence

Full Name of Witness 1

Full Name of Witness 2

NoI agree

Agreement by Employer.

Check either option:

The employer does not elect the employers’ liability of coverage.
The employer terminates the prior nonelection of the employers’ liability coverage.

Employer Information

Authorized Agent

Authorized Agent Email

Relationship to Employer

Authorized Agent City

Authorized Agent County

Authorized Agent State

Full Name of Witness No. 1

Full Name of Witness No. 2

NoI agree