The Workers' Compensation Division no longer accepts the paper version of Form 14-0175, 'Nonelection of Workers' Compensation or Employers' Liability Coverage.'

Please use this form to make a nonelection of coverage as required by Iowa Code section 87.22, when the employer has not been issued a workers' compensation or employers' liability policy.

The proprietor, limited liability company member, limited liability partner, or partner and authorized representative of the employer must agree to the terms in the form in front of two disinterested witnesses. After the form is submitted, you will receive a verification email at the address(es) provided in the form. The information in this form is considered public information. You can find more information on our website about nonelection of coverage.

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