Official State of Iowa Website Here is how you know
Agencies A-Z Programs & Services
  1. Nonelection of Workers' Compensation or Employers' Liability Coverage
  2. Table

Nonelection of Workers' Compensation or Employers' Liability Coverage

Primary tabs

Secondary tabs

Showing 1 - 50 of 2394.   Show 10 | 50 | 100 | 200 | 500 | 1000 | All results per page.
# Submitted User IP address Name of Employer: Type of Entity: Address of Employer's Home Office: Statement 1 Agreement: Statement 2 Agreement: Statement 3 Agreement: Understanding Confirmation: Check Either Alternative (1) or (2): Date: Full Name of Individual: Email: City of Residence: County of Residence: State of Residence: Full Name of Witness 1: Full Name of Witness 2: Signing Indication: Check either alternative (1) or (2): Full Name of Authorized Agent: Email of Authorized Agent: Relationship to Employer of Authorized Agent: City of Residence: County of Residence: State of Residence: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Indication:
2397 2024-07-26 16:49 Anonymous (not verified) 94.188.205.181 Jose Fransisco Jaco Proprietorship 4014 Hubbel Ave 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. 2022-07-26 Jose Fransisco Jaco JacoJF1@outlook.com Des Moines Polk United States teresa Martinez isaias martinez Signed (1) The employer does not elect the employers’ liability coverage. Jose Fransisco Jaco JacoJF1@outlook.com self Des Moines Polk United States Teresa Martinez Isaias Martinez Signed
2396 2024-07-25 21:18 Anonymous (not verified) 94.188.205.178 Curt johnson Proprietorship 1115 33rd st ct moline il 61265 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. 2024-07-25 Curt Johnson csj1635@gmail.com Moline Rock island IL Jillian Griffith Tina Coulter Signed (1) The employer does not elect the employers’ liability coverage. Curt Johnson csj1635@gmail.com Sole Proprietor Moline Rock Island Il Jillian Griffith Tina Coulter Signed
2395 2024-07-25 18:37 Anonymous (not verified) 94.188.205.178 Innovative Assessment Solutions, LLC Limited Liability Company 2500 Crosspark Rd, Suite W140D, Coralville, IA 52241 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. 2024-07-25 Robert L Brennan brennan@innovativeassessmentsolutions.com Iowa City Johnson Iowa Lesa R Hoffman Paul M Wilson Signed (1) The employer does not elect the employers’ liability coverage. Robert L Brennan brennan@innovativeassessmentsolutions.com Partner Iowa City Johnson Iowa Lesa R Hoffman Paul M Wilson Signed
2394 2024-07-25 15:32 Anonymous (not verified) 94.188.205.180 Sweet Caroline's Coffee and Cafe Limited Liability Company 112 S Washington St Bloomfield Iowa 52537 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. 2024-07-25 Haley Sarna sarna1985@yahoo.com Bloomfield Davis Iowa Morgan McCarty Delia Ramirez Signed (1) The employer does not elect the employers’ liability coverage. Haley Sarna sarna1985@yahoo.com Self Bloomfield Davis Iowa Morgan McCarty Delia Ramirez Signed
2393 2024-07-25 11:53 Anonymous (not verified) 94.188.205.173 Carters International Material Handling Equipment Nissi Enterprises Inc. Proprietorship 1508 17th Ave E. Oskaloosa Iowa 52577 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. 2024-07-25 James J Carter cartersintl@lisco.com Oskaloosa Mahaska Iowa Mark Roake Tony Johnson Signed (1) The employer does not elect the employers’ liability coverage. James J CARTER cartersintl@lisco.com Owner Oskaloosa Mahaska Iowa Mark Roake Tony Johnson Signed
2392 2024-07-25 11:50 Anonymous (not verified) 94.188.205.173 Carters International Material Handling Equipment Nissi Enterprises Inc. Proprietorship 1508 17th Ave E. Oskaloosa Iowa 52577 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. 2024-07-25 REBECCA E CARTER cartersintl@lisco.com Oskaloosa Mahaska Iowa Mark Roake Tony Johnson Signed (1) The employer does not elect the employers’ liability coverage. REBECCA E CARTER cartersintl@lisco.com Owner Oskaloosa Mahaska Iowa Mark Roake Tony Johnson Signed
2391 2024-07-25 09:12 Anonymous (not verified) 94.188.205.178 Andrew Heller Proprietorship 3192311923 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. 2024-02-11 Andrew Heller asheller89@gmail.com Dubuque Dubuque Iowa Randi R Taylor Michelle Kaufmann Signed (1) The employer does not elect the employers’ liability coverage. Andrew Heller asheller89@gmail.com Self Dubuque Dubuque IA Randi Taylor Michelle Kaufmann Signed
2390 2024-07-25 09:04 Anonymous (not verified) 94.188.205.179 Andrew Heller Proprietorship 3192311923 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. 2024-02-11 Andrew Heller asheller89@gmail.com Dubuque Dubuque IA Randi R Taylor Michelle Kaufmann Signed (1) The employer does not elect the employers’ liability coverage. Randi R Taylor randi.taylor@balanceig.com Insurance Agent Dubuque Dubuque IA Michelle Kaufmann Alicia Ehlers Signed
2389 2024-07-25 08:50 Anonymous (not verified) 94.188.205.181 Stone Vision llc Limited Liability Company 1234 1st Ave south 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. 2024-07-25 Andrew Cockrum andy@ac-flooring.com Fort Dodge IA United States Corey Simpson Jamie Conrad Signed (1) The employer does not elect the employers’ liability coverage. Andrew Cockrum andy@stonevisionllc.com owner Fort Dodge IA United States cory simpson Jamie Conrad Signed
2388 2024-07-24 10:19 Anonymous (not verified) 94.188.205.178 TOM MACK Proprietorship 3847 TANGELFOOT LN BETTENDORF, IA 52722 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. 2024-07-24 TOM MACK TMACKMARYANN@ME.COM bettendorf scott iowa TELVION JONES ANTONIQUE MATHIS Signed (1) The employer does not elect the employers’ liability coverage. TOM MACK TMACKMARYANN@ME.COM SELF BETTENDORF SCOTT IOWA TELVION JONES ANTONIQUE MATHIS Signed
2387 2024-07-22 15:08 Anonymous (not verified) 94.188.205.178 Davenport Guns LLC Limited Liability Company 3701 Mississippi Ave 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. 2024-07-22 JEANELLE A WESTROM-CREGER jwestrom@davenportguns.com Davenport IA United States Carlton Creger Lionel Sanchez Signed (1) The employer does not elect the employers’ liability coverage. JEANELLE A WESTROM jwestrom@davenportguns.com Owner Davenport IA United States Carlton Creger Lionel Sanchez Signed
2386 2024-07-22 10:07 Anonymous (not verified) 94.188.205.171 Cory's Painting LLC Limited Liability Company Po Box 1161, Cedar Falls, Iowa 50613 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. 2024-07-22 Curtis Witte curtiswitte14@gmail.com Waterloo Black Hawk United States Kari Houle Steven Swanson Signed (1) The employer does not elect the employers’ liability coverage. Cory Koger coryspainting@gmail.com Self CEDAR FALLS Black Hawk United States Kari Houle Steven Swanson Signed
2385 2024-07-21 21:05 Anonymous (not verified) 94.188.205.173 Innovative Assessment Solutions, LLC Limited Liability Company 2500 Crosspark Rd, Suite W140D, Coralville, IA 52241 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. 2024-07-21 Zachary Conrad zach@innovativeassessmentsolutions.com Topeka Shawnee KS Cody Conrad Marvin Bennett Signed (1) The employer does not elect the employers’ liability coverage. Zachary COnrad zach@innovativeassessmentsolutions.com Partner Topeka Shawnee KS Cody Conrad Marvin Bennett Signed
2384 2024-07-20 08:24 Anonymous (not verified) 66.22.12.246 Pro A Painters Limited Liability Company 3220 Hubbell Ave 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. 2024-07-20 Karen Gutierrez valdez andresfabela123@gmail.com Des Moines IA Estados Unidos Andres Ivan Fabela Andres Ivan Fabela Signed (1) The employer does not elect the employers’ liability coverage. Pro A painters andresfabela123@gmail.com Owner Des Moines IA Estados Unidos Andres Ivan Fabela Andres Ivan Fabela Signed
2383 2024-07-19 15:51 Anonymous (not verified) 94.188.205.178 Musa Koech Proprietorship 5555 Vista Dr. 510 West Des Moines, IA 50266 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. 2024-07-19 Musa Koech koechm17@gmail.com West Des Moines Polk IA Leonard Boinett Elijah Ruiru Signed (1) The employer does not elect the employers’ liability coverage. Musa Koech koechm17@gmail.com Contractor West Des Moines Polk IA Leonard Boinett Elijah Ruiru Signed
2382 2024-07-19 10:38 Anonymous (not verified) 94.188.205.178 Diamond Ridge Roofing Proprietorship 1842 Glenwood Circle Des Moines, IA 50320 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. 2024-07-19 Marianna Landeros landerosmary@gmail.com Des Moines Polk Iowa Jessica Newton Tom Newton Signed (1) The employer does not elect the employers’ liability coverage. Marianna Landeros landerosmary@gmail.com owner Des Moines Polk Iowa Jessica Newton Tom Newton Signed
2381 2024-07-18 13:08 Anonymous (not verified) 94.188.205.171 Ashby Psychological Services DBA Family Legacy Counseling Proprietorship 415 NW 88th St #100, Johnston, IA 50131 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. 2024-07-18 Melissa Zizis melissa.elizabeth19@gmail.com Polk City Iowa United States Gina Mele Olivia Stephens Signed (1) The employer does not elect the employers’ liability coverage. Melissa Zizis melissa@familylegacycounseling.com Sub-contractor Polk City Iowa United States Gina Mele Olivia Stephens Signed
2380 2024-07-18 12:36 Anonymous (not verified) 94.188.205.170 Jill Grant Proprietorship 33845 Oakridge Blvd Maxwell Ia, 50161 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. 2024-07-18 Jill Grant Jill.grant@candeoiowa.org Maxwell, IA Story Iowa Lizann Eggers Kim Keller Signed (1) The employer does not elect the employers’ liability coverage. Jill Grant jill.grant@candeoiowa.org Self employed Maxwell Story Iowa Lizann Eggers Kim Keller Signed
2379 2024-07-18 11:53 Anonymous (not verified) 94.188.205.171 Jerry Howe Proprietorship 607 Knotts St. New Virgina, IA 50210 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. 2024-07-18 Jerry Howe howetodoit2@gmail.com New Virgina Iowa United States Dean Dutcher Chad Gates Signed (1) The employer does not elect the employers’ liability coverage. Jerry Howe howetodoit2@gmail.com Self employed New Virgina Warren County Iowa Dean Dutcher Chad Gates Signed
2378 2024-07-17 23:32 Anonymous (not verified) 94.188.205.172 Craig Roberts Proprietorship 8504 crestview drive 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. 2024-07-17 craig roberts craig23r@gmail.com Des Moines ia United States Dan Roberts Michelle Boelling Signed (1) The employer does not elect the employers’ liability coverage. craig roberts craig23r@gmail.com self Des Moines IA United States Dan Roberts Michelle Boelling Signed
2377 2024-07-17 21:29 Anonymous (not verified) 94.188.205.178 Innovative Assessment Solutions, LLC Limited Liability Company 2500 Crosspark Rd, Suite W140D, Coralville, IA 52241 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. 2024-07-17 Ryan Hoffman ryan@innovativeassessmentsolutions.com Omaha Douglas NE Lesa Hoffman Mary Hoffman Signed (1) The employer does not elect the employers’ liability coverage. Ryan Hoffman ryan@innovativeassessmentsolutions.com Partner Omaha Douglas NE Lesa Hoffman Mary Hoffman Signed
2376 2024-07-17 16:25 Anonymous (not verified) 94.188.205.171 Vibrant SCL Limited Liability Company 1776 22nd street STE 202 west Des Moines ,IA 50266 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. 2024-07-17 Julienne Maneza manezajr@gmail.com Johnston Polk Iowa Jean baptiste Mugabe Ivan Mugabe Signed (1) The employer does not elect the employers’ liability coverage. Vibrant SCL tcarew@vibrant-llc.com Vp West Des Moines Polk Iowa Jean baptiste Mugabe Ivan Mugabe Signed
2375 2024-07-17 16:05 Anonymous (not verified) 94.188.205.173 JB Contracting LLC Limited Liability Company 3713 Stover Ave, Spirit Lake, IA 51360 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. 2024-06-01 Brian Wymer thejbbuild@gmail.com Spirit Lake Dickinson IA Bryan Jones John Reed Signed (1) The employer does not elect the employers’ liability coverage. Brian Wymer thejbbuild@gmail.com Owner Spirit Lake Dickinson IA BRyan Jones John Reed Signed
2374 2024-07-17 12:24 Anonymous (not verified) 94.188.205.180 AA&V construction llc Limited Liability Company 1842nw 82 nd st apt 48 50325 Clive IA 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. 2024-07-17 Alexis Alvarado alexiselva31@icloud.com Clive Polk country IA Adam boge Lance Webster Signed (1) The employer does not elect the employers’ liability coverage. Alexis Alvarado alexiselva31@icloud.com Same Clive Polk country IA Adam boge Lance Webster Signed
2373 2024-07-16 17:27 Anonymous (not verified) 94.188.205.171 Maynor Gomez Proprietorship 1604 1st Street 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. 2022-07-16 Maynor Gomez gomezmaynor18@gmail.com Denison Crawford IA Alfredo Villa Josue Garcia Signed (1) The employer does not elect the employers’ liability coverage. Maynor Gomez gomezmaynor18@gmail.com Self Denison Crawford Iowa Alfredo Villa Josue Garcia Signed
2372 2024-07-16 15:07 Anonymous (not verified) 66.22.12.250 Sarah alyce Limited Liability Company 26452 Quinn rd Leon iowa 50144 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. 2024-06-28 Rebecca Bragg beckybragg1984@gmail.com Leon Decatur Iowa Joshua Bragg Shayla Quinn Signed (1) The employer does not elect the employers’ liability coverage. Rebecca Bragg beckybragg1984@gmail.com Self Leon Decatur Iowa Josh Bragg Shayla quinn Signed
2371 2024-07-16 09:43 Anonymous (not verified) 94.188.205.178 Innovative Assessment Solutions, LLC Limited Liability Company 2500 Crosspark Rd, Suite W140D, Coralville, IA 52241 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. 2024-07-16 Anne Wilson anne@innovativeassessmentsolutions.com Iowa City Johnson IA Paul Wilson Caecilia Wilson Signed (1) The employer does not elect the employers’ liability coverage. Anne Wilson anne@innovativeassessmentsolutions.com Partner Iowa City Johnson IA Paul Wilson Caecilia Wilson Signed
2370 2024-07-15 20:03 Anonymous (not verified) 66.22.12.248 Gutters Unlimited Limited Liability Company 5005 NE Jan Rose Pkwy Ankeny IA 50021 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. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2024-07-15 Matthew Kobashigawa matthewkobashigawa@gmail.com Ankeny Polk Iowa Casey Kobashigawa Matthew Kobashigawa Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Matthew Kobashigawa matthewkobashigawa@gmail.com Self Ankeny Polk Iowa Casey Kobashigawa Matthew Kobashigawa Signed
2369 2024-07-15 18:23 Anonymous (not verified) 94.188.205.173 Somatic Peace Therapy Limited Liability Company 420 49th St 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. 2024-07-15 Emily Elliott emily@somaticpeacetherapy.com Des Moines Iowa United States Brian Elliott Harrison Elliott Signed (1) The employer does not elect the employers’ liability coverage. Emily Elliott emily@somaticpeacetherapy.com Owner Des Moines Iowa United States Brian Elliott Harrison Elliott Signed
2368 2024-07-15 16:15 Anonymous (not verified) 94.188.205.179 Vibrant LLC Limited Liability Company 1776 22nd Street - Suite 202, West Des Moines, IA 50266 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. 2024-07-15 Ernestina king Kingderrina@gmail.com west Des Moines IA United States Presha Guidebeck Aleena Nicholson Signed (1) The employer does not elect the employers’ liability coverage. Tory Carew tcarew@vibrant-llc.com VP of Operation West Des Moines Polk Iowa Presha Guidebeck Aleena Nicholson Signed
2367 2024-07-15 15:43 Anonymous (not verified) 94.188.205.171 Daniel Sales Proprietorship 2947 Ovid Ave Des Moines IA 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. 2022-07-15 Daniel Sales lezlylssamar0321@gmail.com Des Moines Polk Iowa Kevin paz Nick Martinez Signed (1) The employer does not elect the employers’ liability coverage. Daniel Sales lezlylssamar0321@gmail.com Self Des Moines Polk Iowa Kevin Paz Nick Martinez Signed
2366 2024-07-12 20:49 Anonymous (not verified) 94.188.205.178 Vibrant SCL Limited Liability Partnership 1776 22nd street STE 202 west Des Moines ,IA 50266 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. 2024-07-12 Julienne Maneza manezajr@gmail.com Johnston Polk Iowa Jean baptiste Mugabe Ivan Mugabe Signed (1) The employer does not elect the employers’ liability coverage. Vibrant SCL carow@vbrark.ic.com Vp West Des Moines Polk Iowa Jean baptiste Mugabe Ivan Mugabe Signed
2365 2024-07-12 15:42 Anonymous (not verified) 94.188.205.171 Marvin Gilberto Proprietorship 2105 32nd St Des Moines 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. 2022-07-12 Marvin Gilberto marbinjilbertoiriarte@gmail.com Des Moines polk Iowa Jose Gonzalez Maria Gonzalez Signed (1) The employer does not elect the employers’ liability coverage. Marvin Gilberto marbinjilbertoiriarte@gmail.com self Des Moines polk iowa Jose Gonzalez Maria Gonzalez Signed
2364 2024-07-12 12:11 Anonymous (not verified) 94.188.205.180 William Miller Proprietorship 1669 110th St Reinbeck IA 50669 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. 2024-06-12 William Miller rosebud54@hughes.net Reinbeck Grundy Iowa Daniel Sinnott Thomas Sinnott Signed (1) The employer does not elect the employers’ liability coverage. William Miller rosebud54@hughes.net Self Reinbeck Grundy Iowa Daniel Sinnott Thomas Sinnott Signed
2363 2024-07-12 11:37 Anonymous (not verified) 94.188.205.179 S&S Industries LLC Limited Liability Company 1106 W Main St 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. 2024-07-12 Spencer Snyder sslawnmtown@gmail.com Marshalltown Marshall IA Tyler Peschong Karis Keislar Signed (1) The employer does not elect the employers’ liability coverage. Tyler Peschong tyler.peschong.w8l3@statefarm.com Insurance Agent Marshalltown Marshall IA Karis Keislar Renee BUrnes Signed
2362 2024-07-10 17:26 Anonymous (not verified) 94.188.207.226 JULIENNE MANEZA Proprietorship 10239 SOUTHERWICK PLACE 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. 2024-07-10 JULIENNE MANEZA manezajr@gmail.com JOHNSTON Iowa United States JEAN BAPTISTE MUGABE IVAN NSHUTI MUGABE Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. JULIENNE MANEZA manezajr@gmail.com Vibrant Homecare and Vibrant SCL JOHNSTON Iowa United States JEAN BAPTISTE MUGABE IVAN NSHUTI MUGABE Signed
2361 2024-07-10 17:20 Anonymous (not verified) 94.188.207.229 Vibrant SCL Limited Liability Company 1776 22nd Street STE 202 West Des Moines, IA 50266 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. 2024-07-10 Ashley Wood ashley.wood0109@gmail.com West Des Moines Dallas IA Ashley Wood Ashley Wood Signed (1) The employer does not elect the employers’ liability coverage. Vibrant SCL tcarew@vibrant-llc.com VP West Des Moines Polk IA Ashley Wood Ashley Wood Signed
2360 2024-07-10 14:37 Anonymous (not verified) 94.188.207.230 Teknephos LLC Limited Liability Company 208 11th Ave SW / Altoona, IA 50009 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. 2024-07-10 Michael Arthur Lambert lumenpro@mchsi.com Altoona IA IA Elizabeth Ann Lambert Neal Michael Lambert Signed (1) The employer does not elect the employers’ liability coverage. Michael Arthur Lambert lumenpro@mchsi.com The same individual in both cases. A single employee company. Altoona IA IA Elizabeth Ann Lambert Neal Michael Lambert Signed
2359 2024-07-10 10:50 Anonymous (not verified) 94.188.205.167 Tyler Stinson Proprietorship 3012 Eastern Avenue 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. 2024-07-10 Tyler Stinson mr.tyler.stinson@gmail.com Cedar Rapids Linn Iowa Jordan Nisiewicz Jordan Loyd Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Johnson MO Jordan Loyd Jake Nagel Signed
2358 2024-07-09 11:10 Anonymous (not verified) 94.188.205.167 BRANDON PONCIN Proprietorship 10 5TH AVE NW FOSTORIA IA 51340 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. 2024-07-08 BRANDON PONCIN PONCINBBJ@GMAIL.COM FOSTORIA CLAY IOWA TAMI KLEIN JOSPEH LORING Signed (1) The employer does not elect the employers’ liability coverage. BRANDON PONCIN PONCINBBJ@GMAIL.COM OWNER FOSTORIA CLAY IOWA TAMI KLEIN JOSEPH LORING Signed
2357 2024-07-09 06:56 Anonymous (not verified) 94.188.207.223 Alex Webb Proprietorship 4019 West Roderweis Rd, Cabot, AR 72023 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. 2024-07-09 Alex Webb frankie.webb@yahoo.com Cabot Pulaski Arkansas Mark Ellis Becky Ellis Signed (1) The employer does not elect the employers’ liability coverage. Ellis Flying Service Inc. fly@ellisflying.com President Newport Jackson Arkansas Alex Webb Becky Ellis Signed
2356 2024-07-08 18:50 Anonymous (not verified) 94.188.207.224 Mehmed Dizdarevic Proprietorship 6417 Lincoln Avenue 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. 2024-07-08 Mehmed Dizdarevic wbog1@yahoo.com Windsor Heights IA United States Amena Jasarevic Fikret Dizdarevic Signed (1) The employer does not elect the employers’ liability coverage. Mehmed Dizdarevic wbog1@yahoo.com Owner Windsor Heights IA United States Amena Jasarevic Fikret Dizdarevic Signed
2355 2024-07-08 16:33 Anonymous (not verified) 94.188.205.168 Martens & Associates PLLC Limited Liability Company 110 E State St Jefferson, IA 50129 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. 2024-07-08 Ross Martens ross.martens@gmail.com Jefferson Greene Iowa Ross Martens Mariah Martens Signed (1) The employer does not elect the employers’ liability coverage. Ross Martens Ross.martens@gmail.com Owner Jefferson Greene Iowa Ross Martens Mariah Martens Signed
2354 2024-07-08 15:59 Anonymous (not verified) 94.188.207.226 It's Lit Fireworks Limited Liability Company 2460 390th St, Sioux Center 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. 2024-07-08 Daniel Winterfeld sarawinterfeld@gmail.com Sioux Center IA United States Peg Eekhoff Abbie Johnson Signed (1) The employer does not elect the employers’ liability coverage. Dan Winterfeld sarawinterfeld@gmail.com Owner Sioux Center IA United States Peg Eekhoff Abbie Johnson Signed
2353 2024-07-08 15:56 Anonymous (not verified) 94.188.207.227 It's Lit Fireworks Limited Liability Company 2460 390th St, Sioux Center 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. 2024-07-08 Sara A Winterfeld sarawinterfeld@gmail.com Sioux Center IA United States Peg Eekhoff Abbie Van Essen Signed (1) The employer does not elect the employers’ liability coverage. Sara A Winterfeld sarawinterfeld@gmail.com Owner Sioux Center IA United States Peg Eekhoff Abbie Johnson Signed
2352 2024-07-08 14:57 Anonymous (not verified) 94.188.205.176 JCC Construction LLC Limited Liability Company 823 E 22nd Ct Des Moines Ia 50317 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. 2024-07-08 Julio A. Cardoza juliocardoza1222@icloud.com Des Moines polk iowa jose mauricio cardoza julian cardoza Signed (1) The employer does not elect the employers’ liability coverage. julio cardoza juliocardoza1222@icloud.com owner des moines polk iowa jose mauricio cardoza julian cardoza Signed
2351 2024-07-08 11:21 Anonymous (not verified) 94.188.205.175 Kennedy Cyiza Proprietorship 1900 locust st 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. 2024-07-08 Kennedy Cyiza kcyiza15@gmail.com west des moines IA United States Sunzu Bigimbia Joseph Jeff Signed (1) The employer does not elect the employers’ liability coverage. Kennedy Cyiza kcyiza15@gmail.com Self west des moines IA United States Sunzu Bigimba Joseph Jeff Signed
2350 2024-07-06 10:23 Anonymous (not verified) 94.188.207.230 Sarah E. Wilson Law Firm, PLC Limited Liability Company 117 NE Trilein Drive, Ankeny, Iowa 50021 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. 2024-07-06 Sarah E. Wilson sarah@sarahwilsonlaw.com Ankeny Polk Iowa Tyler Wilson Elizabeth Jessica Ailenei Signed (1) The employer does not elect the employers’ liability coverage. Sarah E. Wilson sarah@sarahwilsonlaw.com Owner Ankeny Polk Iowa Tyler Wilson Elizabeth Jessica Ailenei Signed
2349 2024-07-03 16:53 Anonymous (not verified) 94.188.207.225 BNC Construction LLC Limited Liability Company 8408 east 56th street south 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. 2024-07-03 BRENT COWMAN bncnam@hotmail.com REASNOR IA United States Rick Waddle Matt Fish Signed (1) The employer does not elect the employers’ liability coverage. BRENT COWMAN bncnam@hotmail.com Owner REASNOR IA United States Matt Fish Rick Waddle Signed
2348 2024-07-02 14:44 Anonymous (not verified) 94.188.205.177 Exteriors By Bradford Limited Liability Company 515 N. Ripley st. Davenport Ia 52803 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. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2024-06-28 Kyle Tschopp kyletschopp180@gmail.com Davenport IA United States Shane Forgie Ashley Stewart Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Kyle Tschopp kyletschopp180@gmail.com Owner/self Davenport IA United States Shane Forgie Ashley Stewart Signed