883 |
2022-02-02 14:07 |
Anonymous (not verified) |
104.201.67.178 |
Juan Monterde |
Proprietorship |
9235 Swanson Blvd |
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. |
2022-01-01 |
Juan Monterded |
s.thomas@nationwideofficecare.com |
Cedar Rapids |
Linn |
Iowa |
Cory Shelton |
Scott D Thomas |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Scott D Thomas |
scottthomascpa@msn.com |
Consultant |
West Des Moines |
IA |
United States |
Rich Darr |
Mari Lopez |
Signed |
884 |
2022-02-02 14:10 |
Anonymous (not verified) |
104.201.67.178 |
Magdalena Lopez Raymundp |
Proprietorship |
2820Pennsylvania Ave, Dubuque, IA 52001 |
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. |
2022-01-01 |
Magdalena Lopez Raymundo |
scottthomascpa@msn.com |
Dubuque |
Dubuque |
Iowa |
Rich Darr |
Mari Lopez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Scott D Thomas |
scottthomascpa@msn.com |
Consultant |
West Des Moines |
IA |
United States |
Rich Darr |
Mari Lopez |
Signed |
405 |
2021-02-17 11:04 |
Anonymous (not verified) |
104.201.67.178 |
CYE Painting |
Limited Liability Company |
5202 SE 31st Ct 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. |
2021-02-17 |
CYE Painting |
marilopez9657@yahoo.com |
Des Moines |
Polk |
Iowa |
Maricela Lopez |
Cruz Cabrera |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maricela Lopez |
marilopez9657@yahoo.com |
N/a |
Des Moines |
Polk |
IA |
Maricela Lopez |
Cruz Cabrera |
Signed |
1119 |
2022-05-18 11:51 |
Anonymous (not verified) |
104.201.75.222 |
Gentry Hardware inc. |
Partnership |
308 5th 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. |
2022-05-18 |
Nathan Dwaine Gentry |
gentrynathan@hotmail.com |
Rockwellcity |
Calhoun |
Iowa |
Emily Bethann Gentry |
Amanda Margaret Albee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nathan Dwaine Gentry |
gentrynathan@hotmail.com |
Owner |
Rockwellcity |
Calhoun |
Iowa |
Emily Bethann Gentry |
Amanda Margaret Albee |
Signed |
1037 |
2022-04-07 08:16 |
Anonymous (not verified) |
104.207.27.18 |
SION LUTHERAN CHURCH |
Proprietorship |
4525 FINCH AVE LAKE MILLS, IA 50450 |
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. |
2021-03-07 |
JANE BRUNSVOLD |
janebrunsvold@yahoo.com |
LAKE MILLS |
WINNEBAGO |
IOWA |
ANDREW STENSRUD |
JILL FLUGUM |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
ANDREW STENSRUD |
ANDREW@STENSRUDINSURANCE.COM |
INSURANCE AGENT |
LAKE MILLS |
WINNEBAGO |
IOWA |
JANE BRUNSVOLD |
JILL FLUGUM |
Signed |
1430 |
2023-01-25 14:50 |
Anonymous (not verified) |
104.222.82.50 |
Pille Ceramic Tile |
Proprietorship |
17645 Guthrie 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. |
2023-01-25 |
Bernie Pille |
blpille@yahoo.com |
Maple River |
Carroll |
IA |
Lisa Pille |
None |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bernie Pille |
blpille@yahoo.com |
Self |
Maple River |
Carroll |
IA |
Lisa Pille |
Cameron Pille |
Signed |
1280 |
2022-08-22 15:48 |
Anonymous (not verified) |
104.222.83.187 |
Cabinet Kulture LLC |
Limited Liability Company |
927 N. West St. Carroll, 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. |
2022-08-22 |
Jordan Ellis |
cabinetkulture@gmail.com |
Carroll |
IA |
United States |
Morgan Ellis |
Ryan Winkelman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cabinet Kulture LLC |
cabinetkulture@gmail.com |
Same person |
Carroll |
IA |
United States |
Morgan Ellis |
Ryan Winkelman |
Signed |
1289 |
2022-09-01 11:06 |
Anonymous (not verified) |
104.222.95.52 |
Alliant Personnel Resources |
Limited Liability Company |
619 N Carroll St, Carroll, IA 51401 |
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. |
2022-09-01 |
Jonathan Sturm |
Jon@AlliantPR.com |
Carroll, IA |
Carroll County |
IA |
Sara Beiter |
Austin Scott |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jon Sturm |
Jon@AlliantPR.com |
Owner |
Carroll, IA |
Carroll County |
Iowa |
Sara Beiter |
Austin Scott |
Signed |
457 |
2021-04-04 17:35 |
Anonymous (not verified) |
104.237.118.236 |
Lundt Transport, LLC |
Limited Liability Company |
3322 Y AVE. FAIRBANK, IA 50629 |
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. |
2021-04-04 |
SAMUEL LUNDT |
samuelrl1998@gmail.com |
FAIRBANK |
Iowa |
Iowa |
CYNTHIA LUNDT |
KATLYN HILL |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SAMUEL LUNDT |
samuelrl1998@gmail.com |
SELF |
FAIRBANK |
FAYETTE |
Iowa |
CYNTHIA LUNDT |
KATLYN HILL |
Signed |
1046 |
2022-04-14 08:11 |
Anonymous (not verified) |
104.36.120.68 |
jet drywall |
Limited Liability Company |
5611 westminster DR #5 cedarfalls IA 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. |
2022-04-14 |
murion jones |
jetdrywall.construction@gmail.com |
cedarfalls |
black hawk |
iowa |
murion parely jones |
murion jones |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
murion jones |
jetdrywal.construction@gmail.com |
owner |
cedarfalls |
black hawk |
iowa |
Murion Jones JR |
Eric Jones |
Signed |