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Nonelection of Workers' Compensation or Employers' Liability Coverage

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Showing 421 - 430 of 2219.   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:
439 2021-03-18 08:09 Anonymous (not verified) 172.58.86.251 Nancy Lopez/Lifetime Roofing and Construction Corpn Proprietorship 2234 Highland St 50315 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. 2021-03-18 Nancy Lopez/ Lifetime Roofing and Construction Corp info@lifetimeroofingdsm.com Des Moines Polk I A Noe Ordaz Fidel Rubio Signed (1) The employer does not elect the employers’ liability coverage. Nancy Lopez info@lifetimeroofingdsm.com Owner Des Moines Polk IA Noe Ordaz Fidel Rubio Signed
440 2021-03-18 08:11 Anonymous (not verified) 66.188.136.150 Jeffrey Gardner Proprietorship 3020 W 1st St., Davenport, IA 52804 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. 2021-03-17 Jeffrey Gardner kschumacher@tricorinsurance.com Davenport Polk IA Russell Masartis Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Jeffrey Gardner kschumacher@tricorinsurance.com Same Davenport Polk IA Russell Masartis Shuree Behr Signed
442 2021-03-22 12:14 Anonymous (not verified) 149.20.235.228 Tim Bruck Construction Inc. Proprietorship 348 Highway 44 Rd. Porstmouth, IA 51565 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. 2021-03-22 Timothy Richard Bruck timrbruck@gmail.com Portsmouth Shelby Iowa Heath Ryan Stein Faith Nicole Bruck Signed (1) The employer does not elect the employers’ liability coverage. Tim Richard Bruck timrbruck@gmail.com Self Portsmouth Shelby Iowa Heath Ryan Stein Faith Nicole Bruck Signed
443 2021-03-22 13:22 Anonymous (not verified) 167.127.218.244 Romero Carpentry Proprietorship 2060 King Ave, Apt 19, 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. 2021-03-22 Jose Wilber Romero Batres Josew.batres@icloud.com Des moines Polk United States Gabriela Cecibel Chicas David Antonio Barrera Serrano Signed (1) The employer does not elect the employers’ liability coverage. Jose Wilber Romero Batres Josew.batres@icloud.com Self Des Moines Polk Iowa Gabriela Cecibel Chicas David Antonio Barrera Serrano Signed
444 2021-03-22 16:26 Anonymous (not verified) 207.191.204.10 Robert G. Wright Jr, Proprietorship 2721 Elm St Dubuque, IA 52001 PO Box 475 Dubuque, IA 52004 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. 2021-03-20 Robert G. Wright Jr, robertw1963@gmail.com Dubuque Dubuque Iowa Brian Kregal Lynda Howell Signed (1) The employer does not elect the employers’ liability coverage. Robert G. Wright Jr, robertw1963@gmail.com Owner Dubuque Dubuque Iowa Brian Kregel Lynda Howell Signed
445 2021-03-23 12:34 Anonymous (not verified) 172.58.84.232 XD PAINTING Limited Liability Company 1233 Herold Ave Des Moines Iowa 50315 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. 2021-03-23 Daniel Alcaraz Suarez xdpainting@gmail.com Des Moines Polk county Iowa Anthony Maland Marcus Ross Signed (1) The employer does not elect the employers’ liability coverage. Daniel Alcaraz Suarez xdpainting@gmail.com None Des Moines Polk county Iowa Anthony maland Marcus Ross Signed
446 2021-03-23 12:39 Anonymous (not verified) 174.198.72.209 Final Finish llc Limited Liability Company 3824 12th st Des Moines Iowa 50313 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. 2021-03-23 Wesley Robert Detman wesdet@gmail.com Drs Moines Polk Iowa Leah Laxton Lucas Laxton Signed (1) The employer does not elect the employers’ liability coverage. Wesley Robert Detman wesdet@gmail.com Owner Des Moines Polk Iowa Leah Laxton Lucas Laxton Signed
447 2021-03-24 14:09 Anonymous (not verified) 208.90.15.53 Gabe Saenz, LLC Limited Liability Company PO Box 53 Humboldt, IA 50548 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. 2021-03-24 Gabriel Saenz gsaenzh@gmail.com Humboldt Humboldt Iowa Lance DeWinter Cathy Schipull Signed (1) The employer does not elect the employers’ liability coverage. Gabriel Saenz gsaenzh@gmail.com Owner Humboldt Humboldt Iowa Lance DeWinter Cathy Schipull Signed
448 2021-03-25 10:18 Anonymous (not verified) 172.58.83.161 Limited Liability Company 201 Ne 44th St , Apt 111 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. 2021-03-25 Aldo Monroy reyes Aldogmonroy@gmail.com Ankeny Polk county IOWA Elizabeth lopez Brayan monroy Signed (1) The employer does not elect the employers’ liability coverage. Aldo Monroy Aldogmonroy@gmail.com None Ankeny Polk county IOWA Aldo Monroy Brayan monroy Signed
449 2021-03-25 10:53 Anonymous (not verified) 174.198.73.94 A&F Painting llc Limited Liability Company 411 E Dunham 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. 2021-03-25 Miguel Afanador Olguin mafanador02@gmail.com Des Moines Polk Iowa Alfonzo Afanador Noemi Afanador Signed (1) The employer does not elect the employers’ liability coverage. Miguel Afanador Olguin mafanador02@gmail.com Owner Des Moines Polk Iowa Alfonzo Alfanador Noemi Alfanador Signed