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Corporation Information
Corporation Name
Corporation Address
Attestation by Individual
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 choose to terminate my previous rejection of coverage. I understand that by filing this termination, I will terminate the rejection of coverage that I previously filed. I also understand that after filing this termination, my status will be the same as if the rejection of coverage had not been made. I also understand that this termination shall 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
Email
City of Residence
County of Residence
State of Residence
Full Name of Witness 1
Full Name of Witness 2
I agree
No
I agree
I agree
Agreement by Corporation.
Check Either Alternative:
Check Either Alternative:
The corporation rejects the employers’ liability coverage.
Check Either Alternative:
The corporation terminates the prior rejection of the employers’ liability coverage.
Corporation Information
Full Name of Authorized Agent
Email of Authorized Agent
Relationship to Employer of Authorized Agent
Employer City of Residence
Employer County of Residence
Employer State of Residence
Full Name of Witness No. 1
Full Name of Witness No. 2
I agree
No
I agree
I agree
