The president, vice president, secretary, and treasurer of a corporation other than a family farm corporation, but not to exceed four officers per corporation, may exclude themselves from workers' compensation coverage under chapters 85, 85A, and 85B by knowingly and voluntarily rejecting workers' compensation coverage by signing, and attaching to the workers' compensation or employers' liability policy, initially and upon renewal of the policy, a written rejection, or if such a policy is not issued, by signing a written rejection which is witnessed by two disinterested individuals who are not, formally or informally, affiliated with the corporation and which is filed by the corporation with the industrial commissioner, in substantially the following form: Q $KIP$ 1 P MARGINS C *T( REJECTION OF WORKERS' COMPENSATION ~~ OR EMPLOYERS' LIABILITY COVERAGE ~~ Q $KIP$ 1 P MARGINS L
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. P MARGINS L *T)(
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. P MARGINS L *T)(
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 my employment with the corporation. (Check either alternative (1) or (2):) P MARGINS L *T)(
(1) I reject the employers' liability coverage.
(2) I decline to reject the employers' liability coverage. P MARGINS F Q $KIP$ 1 $T6@Signed $DTL ~~ $T6@Corporate Office $DTL ~~ $T6@Date $DTL6@ ~~ $T6@City, County, State ~~ $T6@of Residence $DTL ~~ Q $KIP$ 1 Witness $DTL10@ ~~ Witness $DTL10@ ~~ Q $KIP$ 1 P MARGINS L *T)(
I also understand that the signing of this statement and checking of alternative (1) below by an authorized agent of the corporation 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. (Check either alternative (1) or (2):) P MARGINS L *T)(
(1) The corporation rejects the employers' liability coverage.
(2) The corporation declines to reject the employers' liability coverage. P MARGINS F Q $KIP$ 1 $T6@Signed $DTL ~~ $T6@Relationship to Corporation $DTL ~~ $T6@Date $DTL ~~ $T6@City, County, State ~~ $T6@of Residence $DTL ~~ Q $KIP$ 1 Witness $DTL10@ ~~ Witness $DTL10@ ~~ Q $KIP$ 1 P MARGINS L *T)
The rejection of workers' compensation coverage is not enforceable if it is required as a condition of employment. A corporate officer who signs a written rejection filed with the industrial commissioner may terminate the rejection by signing a written notice of termination which is witnessed by two disinterested individuals, who are not, formally or informally, affiliated with the corporation and which is filed by the corporation with the industrial commissioner.
83 Acts, ch 36, § 5, 7, 8
Referred to in § 85.1, 517.6
Iowa General Assembly
Search: Iowa Code 1997
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