Submission #567

Submission information
Submitted by Anonymous (not verified)
Thu, 2021-07-08 14:22
50.82.130.211
Information About Employer
Black Cat Ice Cream, LLC
Limited Liability Company
1031 Office Park Road, Suite #4, West Des Moines IA 50265
Agreements by Individual.
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.
I understand that my nonelection 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 employment with the employer.
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.
(1) I am not electing the employers’ liability coverage.
Individual Information
Thu, 2021-06-10
Alex Carter
Des Moines
Polk
Iowa
Mary Brown
Kaytee Stearns
Signed

By selecting the "Signed" button above, I hereby sign this form and, in doing so, swear or affirm that:

  1. The information I have provided is true and correct to the best of my knowledge; 
  2. I am a proprietor, limited liability company member, limited liability partner, or partner of the employer;
  3. I am one of not more than four corporate officers rejecting coverage;
  4. I am signing this form in front of the two witnesses I have identified; and
  5. Both of the witnesses are disinterested individuals who are not, formally or informally, affiliated with the employer.
  6. I understand that this form is a public record open to public inspection under Iowa Code chapter 22 and section 87.22.
     
Agreement by Employer.
(1) The employer does not elect the employers’ liability coverage.
Employer Information
Black Cat Ice Cream, LLC
Self
Des Moines
Polk
Iowa
Mary Brown
Kaytee Stearns
Signed

By selecting the "Signed" button above, I hereby sign this form and swear or affirm that:

  1. The information I have provided is true and correct to the best of my knowledge; 
  2. I am authorized to elect or decline to elect employers’ liability coverage on behalf of the employer.
  3. I am signing this form in front of the two witnesses I have identified; and
  4. Both of the witnesses are disinterested individuals who are not, formally or informally, affiliated with the employer.
  5. I understand that this form is a public record open to public inspection under Iowa Code chapter 22 and section 87.22.