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Corporation Information
Corporation Name
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Corporation Address
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Attestation by Individual
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Attestation by Individual
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 employment with the corporation. I also understand that an authorized agent of the corporation, by agreeing to these statements and , 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.
Attestation by Individual
I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me
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 Corporation.
Check either alternative Emp
Check either alternative Emp
(1) The corporation rejects the employers’ liability coverage.
Check either alternative Emp
(2) The corporation declines to reject the employers’ liability coverage.
Corporation Information
Full Name of Authorized Agent
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Email of Authorized Agent
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Relationship to Employer of Authorized Agent
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City of Residence Emp
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County of Residence Emp
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State of Residence Emp
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Full Name of Witness No. 1
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Full Name of Witness No. 2
*
I agree
I agree
No
I agree
Yes
