Non-Statutory Volunteer Coverage Background
Who is eligible for coverage?
Any person who is a non-statutory volunteer of an Iowa Municipalities Workers’ Compensation Association (IMWCA) member, does not receive remuneration and is not covered by the Iowa Workers’ Compensation Act is eligible for this coverage. If your municipality elects volunteer coverage, all eligible non-statutory volunteers must be covered.
When is a volunteer covered?
A volunteer is covered while he or she is:
- Participating in a volunteer activity sponsored by and under the direct supervision of the IMWCA member.
- Traveling directly to and from such activities.
Description of Benefits
Limits: This coverage provides medical benefits only. Medical benefits paid under this endorsement shall not exceed $25,000 per occurrence or extend beyond two years from the date of injury.
Excess Coverage: This coverage is in excess of any other applicable insurance in force. It essentially "fills in" other plans’ deductibles and coinsurance as well as pays remaining covered expenses if benefits of
other plans are exhausted or if the volunteer has no other medical insurance.
Premium: $10 per volunteer per year with minimum annual premium of $100. This endorsement may be added at renewal or any time throughout the year.
Reporting: Members are required to retain a copy of the signed application form for each volunteer and have them available for the annual payroll audit. The forms also provide a mechanism for certification of claims.
Claims: Claims should be submitted through Company Nurse, following the same process that employees use. When asked for whom they work or who their employer is, the injured volunteer should give the name of the IMWCA member for whom they are volunteering.
Iowa Municipalities Workers’ Compensation Association | Rev. 4.2013
Non-Statutory Volunteer Coverage Application
Coverage valid for fiscal year July 1, 2022 through June 30, 2023 (Please indicate years)
This application is to be completed by the department supervisor, with signatures from the volunteer before beginning work. If the volunteer is under age 18, the signature of a parent/guardian is also required. Please retain a copy for your records and for audit reporting purposes. NOTE: This application is good for one fiscal year. If work extends into the next fiscal year (beyond June 30), a new application must be completed for coverage to be in effect.
Supervisor should review the following with each volunteer:
- Safety rules and enforcement procedure
- Proper use of tools and equipment
- Proper work shoes and other personal protective equipment
- Special hazards of assignment
- Department emergency procedures
Release and Waiver of Liability
The undersigned acknowledges and agrees as follows:
- The undersigned has offered to provide certain work or services to the Member and the status of the undersigned while performing such work or services is that of a non-statutory volunteer (hereinafter “volunteer”).
- The volunteer is not considered an employee of the Member and is not entitled to any benefits under the Iowa Workers’ Compensation Law for injury incurred while providing work or services regardless of the cause of the injury.
- The Member has purchased a limited amount of excess insurance to cover any medical expenses incurred by the volunteer as a result of injury incurred while the volunteer is providing such work or services, and the payment of these medical expenses is to be made in accordance with the terms of the Description of Benefits attached to this application.
- The volunteer specifically waives the right to any other benefits, reimbursements or damages as a result of injuries which the volunteer may incur while providing such work or services.
- The volunteer specifically releases, waives and covenants not to sue the Member and/or IMWCA for injury or death caused by the negligence of other volunteers or of officers, agent representatives or employees of the Member which may occur while the volunteer is performing such work or services for the Member.
The undersigned has read and voluntarily signs the release and waiver of liability and further agrees that no
oral representations, statements or inducements apart from the foregoing written agreement have been made.
Non-statutory Volunteer Coverage Form
