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403.31-E - Workers' Compensation Form

Click here to download the Workers' Compensation Form

During the 1984 General Assembly, the Legislature enacted Senate File 2295, which amended Section 85.38 of the Iowa Code to add the following:

Prohibition of Supplementation of Workers’ Compensation Benefits: A public employer shall not supplement an employee’s workers’ compensation benefits by reducing the employee’s sick leave, vacation leave, or earned compensatory time entitlements unless the employer first notifies the employee of the employee’s options to supplement and the employee elects to so supplement.

The insurance company will not pay for the first three (3) days of absence until after the employee’s absence exceeds 14 days.

Based on the above information, please choose one of the following:

_____ No, I do not want my workers’ compensation benefits supplemented

_____ Yes, I do want my workers’ compensation benefits supplemented with sick leave pay

Employee's Printed Signature

__________________________________________    _________________
Employee's Signature                                                                             Date

Adopted: 2/09
Reviewed: 3/11; 12/11; 4/13; 9/14; 8/17; 6/20; 4/23
Related Policy: 403.31