150 Des Moines Street
Des Moines, IA 50309-1836
Phone: 515-725-5612/515-725-5608 | Fax: 515-242-5076
firstname.lastname@example.org | www.iowaelevators.gov
Application for Elevator Special Inspector Commission
Other QEI certifying agency
High School and year graduated
If any of the information above changes, I will notify the Division of Labor within 30 days of the change. I understand and agree that I will
need to apply for a new commission if I change jobs. I agree that should I not maintain my QEI certification, my Iowa Special Inspector
Commission becomes null and void. I certify that the information on this form and the attachments is true and accurate to the best of my
knowledge. I understand the Division of Labor may deny this application or revoke my commission if I knowingly make false or fraudulent
statements. I agree by making this application to receive and accept service for any official notice or mailings from the Division of Labor at
either of my addresses listed above, pursuant to Iowa code section 17A.2. I certify that I have read and understand the Iowa code and
administrative rules found at www.iowaelevators.gov. I also understand that I may meet with the Chief Inspector for additional information.
Send the completed application with following attachments to the address above:
1. Copy of the applicant’s current, valid QEI certification
2. $60.00 annual fee (check or money order made out to Division of Labor – Elevator Safety)
3. Proof of insurance. The applicant shall provide evidence of insurance covering liability for death or injury caused by acts or omissions
by applicant. The minimum required insurance coverages are (employer may hold the policy):
$1,000,000 for bodily injury or death of one person in an accident
$5,000,000 for bodily injury or death of more than one person in an accident
$100,000 for property damage in one accident.
Iowa Code Chapters 252J and 272D require special inspector commissions to be maintained by social security number. If you withhold your social security
number, this application will be denied. Your social security number may be shared with the other government agencies. If you are behind in payments, this or
future applications may be denied, or your special inspectors commission may be suspended or revoked.
Please list the last three years of full time work experience in the construction, installation, repair or inspection of devices regulated by the Iowa
State Elevator Code. If additional space is needed, please attach a separate sheet of paper to the application.
Employer’s name, address and phone number
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