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The Filliable 14 0061 form is an important document for corporate officers in Iowa who wish to exclude themselves from workers' compensation and employers' liability coverage. This form is utilized under Iowa Code section 87.22 and allows up to four corporate officers, excluding those from family farm corporations, to voluntarily opt out of this coverage. Completing the form involves providing basic corporate information, such as the corporation's name and address, as well as the names and signatures of the officers seeking exclusion. Each officer must clearly indicate their choice regarding employers’ liability coverage—either rejecting it entirely or opting to keep it. In order to ensure the validity of the rejection, the form must be signed in the presence of two witnesses who are not affiliated with the corporation. Additionally, the rejection cannot be enforced if it is a condition of employment, offering an important protection for workers. There are also provisions for an officer to terminate their prior rejection if they so choose. The completed form must be attached to the workers' compensation or employers’ liability insurance policy, or if no policy is in effect, submitted directly to the Iowa Workers' Compensation Division. Information provided within this document is open for public inspection, ensuring transparency in the process.

Filliable 14 0061 Example

DIVISION OF WORKERS' COMPENSATION 1000 EAST GRAND AVENUE

DES MOINES, IOWA 50319

14-0061 (6-03)

CORPORATION NAME:_______________________________________________________________________________________

ADDRESS (Include Street, City, State and Zip Code)____________________________________________________________

____________________________________________________________________________________

CORPORATE OFFICER EXCLUSION FROM WORKERS’ COMPENSATION OR EMPLOYERS’ LIABILITY COVERAGE

Iowa Code section 87.22.

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, 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 workers' compensation commissioner, in substantially the following form:

REJECTION OF WORKERS’ COMPENSATION OR EMPLOYERS’ LIABILITY COVERAGE

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 my employment with the corporation. Check either alternative (1) or (2):

(1)I reject the employers’ liability coverage.

(2)I decline to reject the employers' liability coverage.

NAME (TYPED AND SIGNED):_________________________________________________________________________________________________________________

CORPORATE OFFICE_______________________________________________________________________________DATE ___________________________________

CITY, COUNTY, STATE OF

RESIDENCE__________________________________________________________________________________________________________________

WITNESS_________________________________________________________________________________________________________________________________________

__

WITNESS_________________________________________________________________________________________________________________________________________

__

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):

(1)The corporation rejects the employers’ liability coverage.

(2)The corporation declines to reject the employers’ liability coverage.

NAME (TYPED AND SIGNED) _____________________________________________________________________________________________________________

RELATIONSHIP TO CORPORATION______________________________________________________________DATE __________________________________

CITY, COUNTY, STATE OF

RESIDENCE___________________________________________________________________________________________________________________

WITNESS_______________________________________________________________________________________________________________________

WITNESS_______________________________________________________________________________________________________________________

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 workers' compensation 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 workers' compensation commissioner.

TO BE ATTACHED TO THE CORPORATION WORKERS’ COMPENSATION OR EMPLOYERS’ LIABILITY INSURANCE POLICY. IF NO POLICY IS IN EFFECT THEN TO BE MAILED TO IOWA WORKERS' COMPENSATION DIVISION, 1000 EAST GRAND AVENUE, DES MOINES, IOWA 50319

THE INFORMATION PROVIDED WILL BE OPEN FOR PUBLIC INSPECTION UNDER IOWA CODE §22.11.

Form Characteristics

Fact Name Details
Form Purpose This form enables corporate officers to voluntarily exclude themselves from workers' compensation coverage under specific conditions in Iowa.
Governing Law The operation of this form is governed by Iowa Code section 87.22, along with chapters 85, 85A, and 85B related to workers' compensation.
Eligible Individuals Only the president, vice president, secretary, and treasurer of a corporation can exclude themselves, not exceeding four officers total.
Rejection Steps To reject coverage, the corporate officer must sign and witness a written rejection, which is then filed with the workers' compensation commissioner.
Witness Requirement The rejection form must be witnessed by two unaffiliated individuals, ensuring the validity of the signing process.
Termination of Rejection A corporate officer can terminate their rejection by signing a written notice, also requiring two disinterested witnesses.
Public Inspection Information submitted via this form is open to public inspection as per Iowa Code §22.11, ensuring transparency.
Attachment Requirement This rejection form must be attached to the workers' compensation or employers' liability policy, or mailed to the Iowa Workers' Compensation Division if no policy is effective.

Guidelines on Utilizing Filliable 14 0061

Filling out Form 14 0061 is a crucial step for corporate officers who want to exclude themselves from workers' compensation and employers' liability coverage in Iowa. Ensure you have all the necessary information handy, such as your corporate details and signatures from the required witnesses. After completing the form, you will need to submit it either by attaching it to your insurance policy or mailing it directly to the Iowa Workers' Compensation Division.

  1. Start by entering the Corporation Name in the designated space at the top of the form.
  2. Fill in the Address field, ensuring to include the street, city, state, and zip code.
  3. In the section titled Corporate Officer Exclusion from Workers’ Compensation or Employers’ Liability Coverage, read the provided statement carefully.
  4. Sign your name in the Name (Typed and Signed) field provided.
  5. Write down the Corporate Officer title you hold below your name.
  6. Enter the Date when you are completing the form.
  7. In the City, County, State of Residence section, fill in the appropriate information.
  8. Two witnesses need to sign. Provide their names and collect their signatures in the Witness fields.
  9. Check either alternative (1) or (2) to indicate your choice regarding employers’ liability coverage. Make sure to clarify your decision.
  10. If applicable, fill out the section regarding the corporation's authorized agent, signing and providing their name, relationship to the corporation, and date.
  11. Have the authorized agent's witnesses sign below their details in the designated witness fields.
  12. Review the completed document to ensure all information is accurate and legible.
  13. Finally, either attach the form to your corporation’s workers' compensation policy or mail it to the Iowa Workers' Compensation Division, using the provided address.

What You Should Know About This Form

What is the purpose of the Fillable 14 0061 form?

The Fillable 14 0061 form is used by corporate officers in Iowa to exclude themselves from workers’ compensation and employers' liability coverage. This is applicable under specific conditions outlined in Iowa Code section 87.22, allowing up to four corporate officers to voluntarily reject this coverage.

Who is eligible to use the Fillable 14 0061 form?

The form is intended for the president, vice president, secretary, and treasurer of a corporation, excluding family farm corporations. Each corporation can have a maximum of four officers sign this form to exclude themselves from workers’ compensation coverage.

What are the steps to complete the Fillable 14 0061 form?

To complete the form, a corporate officer must fill out the name of the corporation and its address. They should then sign the form, affirming their decision to reject workers’ compensation coverage. Additionally, the signatures must be witnessed by two individuals who are not affiliated with the corporation. If there is no workers' compensation insurance policy in effect, the completed form should be mailed to the Iowa Workers' Compensation Division.

Can a corporate officer change their mind after signing the form?

Yes, a corporate officer can terminate their rejection of coverage. This requires a written notice of termination to be signed and witnessed in the same manner as the original rejection. The termination notice must also be filed with the workers' compensation commissioner.

What happens if the rejection of coverage is required as a condition of employment?

The rejection of workers’ compensation coverage is not valid if it is mandated as a part of the employment conditions. This ensures that corporate officers are not pressured into waiving their rights to coverage as a stipulation of their employment.

Where should the Fillable 14 0061 form be submitted?

If the corporation has a workers’ compensation or employers’ liability insurance policy, the completed form should be attached to that policy. If no policy exists, the completed form should be mailed directly to the Iowa Workers’ Compensation Division at 1000 East Grand Avenue, Des Moines, Iowa 50319.

Common mistakes

Filling out the Fillable 14 0061 form can seem straightforward, but many individuals make common errors that can lead to issues later. One major mistake is failing to provide the complete corporate name and address. This information must be accurate and thorough to ensure that the form is processed correctly. Omitting details like zip code or using an outdated corporate name can delay the acceptance of the rejection.

Another frequent error involves the signatures required on the form. Both the corporate officer and witnesses must sign the document properly. Some individuals mistakenly assume that just one witness is sufficient or that a signature is not necessary if the form is being submitted electronically. In reality, two disinterested witnesses are essential, and their absence can invalidate the rejection.

Many people overlook the importance of clarity in their typed and signed name. When completing the form, ensure that both your typed and handwritten signatures match exactly. Discrepancies may raise questions or lead to further complications during processing. It's critical to take the time to double-check these details.

Additionally, there's the issue of not checking the appropriate alternative regarding employers' liability coverage. Whether rejecting or declining to reject the coverage under the provided options, it’s imperative that this section is completed accurately. A simple mistake here could mean the rejection is not correctly registered, affecting future liability issues.

Finally, people often fail to understand the implications of their rejection. Many sign the form without fully grasping that rejecting workers' compensation coverage can have significant legal ramifications. It’s essential to read the form thoroughly and understand the legal consequences before signing. Knowledge about how this impacts rights to compensation is vital to making an informed decision.

Documents used along the form

The Fillable 14 0061 form is crucial for corporate officers in Iowa who choose to exclude themselves from workers' compensation and employers' liability coverage. Alongside this form, several other documents may be needed for compliance or to establish coverage. Below is a list of related forms and documents that are commonly used in conjunction with the Fillable 14 0061 form.

  • Workers' Compensation Insurance Policy: This document outlines the coverage terms and conditions for workers' compensation if the corporation opts for such coverage.
  • Corporate Resolution: This form records the corporation's decision-making process regarding the exclusion of officers from workers' compensation coverage.
  • Notice of Rejection: A document confirming that the corporate officers have formally rejected workers' compensation coverage, often required to be filed with the commissioner.
  • Witness Statements: These are statements from two disinterested witnesses affirming the voluntary rejection of coverage by the corporate officers.
  • Termination Notice: If a corporate officer decides to terminate their rejection, this document is required to notify the workers' compensation commissioner.
  • Employer's Liability Coverage Form: If employers’ liability coverage is chosen, this form outlines the specifics of that additional coverage.
  • Certificate of Insurance: This document provides evidence that the corporation has insurance coverage, if applicable, for liability and workers' compensation.
  • Claims Reporting Form: Required to document any workplace injuries that may occur, ensuring compliance with reporting standards.
  • Employee Handbook: A guiding document that informs all employees of their rights and the protocols related to workplace safety and workers' compensation.
  • State-Specific Compliance Forms: Various forms that may be required by the state for additional compliance concerning workers' compensation laws.

These documents work collectively to ensure that corporate officers are informed of their rights and responsibilities regarding workers' compensation coverage. Proper completion and submission of these forms can help avoid potential legal issues in the future.

Similar forms

  • Form 14-0070: Similar in purpose, this form allows corporate officers to formally reject workers' compensation coverage. It outlines the conditions under which this rejection is permissible, echoing the language and requirements found in the 14-0061.
  • Form 14-0080: This document serves as a notice of rejection for employers’ liability coverage. Like the 14-0061, it requires signatures from both the officer and witnesses, confirming awareness of the implications of declining coverage.
  • Form 14-0050: The structure of this form mirrors that of the 14-0061, providing a mechanism for corporate officers to file exclusions while ensuring compliance with state laws.
  • Form 14-0020: This document allows for workers to report a rejection of workers’ compensation coverage. It maintains similar witness requirements, emphasizing the need for transparency and accountability.
  • Form WC-300: Used for documenting the employee's rejection of workers' compensation benefits, this form shares similar requirements for signatures and witness attestations as seen in the 14-0061.
  • Form WC-100: This coverage rejection form is specifically for small business owners. It has similar legal requirements and implications regarding coverage rejection, paralleling the process outlined in the 14-0061.
  • FC-003: This form is used for family farm corporations to formally decline workers’ compensation coverage. Its similarity lies in the corporate structure and specific exemptions it provides.
  • Form 14-0090: This document allows for the termination of a previously filed rejection, maintaining the same witness requirements as the 14-0061 for valid cancellation.
  • Form DWC-102: This form is utilized for documenting a corporate officer's decision to enroll in or reject coverage. Its composition and objectives parallel those established in the 14-0061.
  • Form 14-0040: This is the employer's acknowledgment of an insurance policy. It relates to the 14-0061 by providing a framework for documenting corporate decisions regarding workers' compensation and employers’ liability.

Dos and Don'ts

When completing the Filliable 14 0061 form, it is essential to be thorough and accurate in order to ensure compliance and avoid any potential issues. The following list highlights key actions to take and avoid when filling out this form.

  • Do verify that all required fields are filled in completely.
  • Do read the instructions carefully to understand the implications of your choices.
  • Do ensure that witnesses are truly disinterested individuals not affiliated with the corporation.
  • Do keep a copy of the signed rejection form for your records.
  • Don't make any alterations or corrections on the form; use a new form if needed.
  • Don't rush through the process; take your time to ensure accuracy and completeness.

By following these guidelines, you can enhance the likelihood of a smooth experience when submitting the Filliable 14 0061 form.

Misconceptions

There are several common misconceptions about the Fillable 14 0061 form that can lead to confusion. Here are six of them:

  • Misconception 1: All corporate officers must have workers' compensation coverage.
  • This is not true. Officers can choose to exclude themselves from coverage, but they must do so knowingly and voluntarily by signing the rejection form.

  • Misconception 2: Once a corporate officer rejects coverage, they can never get it back.
  • This misconception is incorrect. A corporate officer can terminate their rejection by submitting a written notice, as long as certain witnessing conditions are met.

  • Misconception 3: The rejection needs to be notarized.
  • No, the rejection does not need notarization. It only requires the signatures of two disinterested witnesses not affiliated with the corporation.

  • Misconception 4: The rejection of coverage applies to all injuries, regardless of circumstances.
  • This is misleading. The form specifically states that rejecting coverage does not waive rights related to personal injuries sustained during employment.

  • Misconception 5: Every corporate officer can reject coverage, regardless of the corporation type.
  • This is partially true. Only certain officers of non-family farm corporations can exclude themselves, and the number is limited to four.

  • Misconception 6: The Fillable 14 0061 form is just a formality and serves no real purpose.
  • This is far from the truth. The form is critical in establishing a corporate officer's informed decision about their coverage and ensures compliance with Iowa law.

Key takeaways

Filling out the Filliable 14 0061 form can seem daunting at first. However, understanding the key points can simplify the process significantly. Here are some essential takeaways to keep in mind:

  • Purpose of the Form: This form is designed for corporate officers wishing to exclude themselves from workers' compensation and employers’ liability coverage.
  • Identification: Clearly state the name of the corporation and its address at the top of the form. This ensures that the proper entity is recognized.
  • Eligibility: Not all corporate officers can exclude themselves; only the president, vice president, secretary, and treasurer of a corporation (up to four officers) qualify for exclusion.
  • Informed Decision: Signing the rejection means you are doing so knowingly and voluntarily. Take the time to understand the implications before proceeding.
  • Witness Requirement: If you decide to reject coverage without an existing policy, two disinterested witnesses must be present when you sign the rejection statement.
  • Options for Coverage: You must check either alternative (1) or (2) regarding employers' liability. Make sure to choose the option that reflects your decision.
  • Signature and Relationship: Ensure that your name is typed and signed. If an authorized agent is signing for the corporation, their relationship should be clearly stated.
  • Termination of Rejection: This rejection can be reversed if desired. To terminate, a written notice must again be witnessed by two disinterested individuals.
  • Filing Instructions: Attach this rejection form to the corporation's workers' compensation policy or mail it directly to the Iowa Workers’ Compensation Division if no policy exists.
  • Public Inspection: Be aware that the information submitted will be available for public inspection as per Iowa Code §22.11.

Completing this form accurately is crucial. Taking these key points into consideration can help ensure a smooth process for you and your corporation.