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Nonelection of Workers' Compensation or Employers' Liability Coverage

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Showing 1 - 10 of 2227.   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:
1882 2023-10-27 10:40 Anonymous (not verified) 94.188.205.166 Ron's SIding and Construction Proprietorship 6097 26th 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. 2025-02-02 Ron Heggebo heggebojessica@yahoo.com Vinton Benton IA Jessica Heggebo Jessica Heggebo Signed (1) The employer does not elect the employers’ liability coverage. Ronnie Heggebo heggebojessica@yahoo.com self Vinton Benton IA Jessica Heggebo Jessica Heggebo Signed
2226 2024-05-16 09:35 Anonymous (not verified) 94.188.207.226 Paradigm, LLC Limited Liability Company 1897 Rose Ave, Panora, IA 50216 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. 2024-05-16 Kane Powell supernovakane@gmail.com Panora Guthrie Iowa Robert Carr Sheri Meinecke Signed (1) The employer does not elect the employers’ liability coverage. Kane Powell supernovakane@gmail.com Self Panora Guthrie Iowa Robert Carr Sheri Meinecke Signed
2229 2024-05-16 11:12 Anonymous (not verified) 94.188.207.227 PRISCILLA E. MBU Proprietorship 155 PRAIRIE BLUFF DR, WAUKEE, IOWA 50263 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. 2024-05-16 PRISCILLA E. MBU herturnon@gmail.com WAUKEE DALLAS IOWA JUDITH WINGO SPENCER JOHNSON Signed (1) The employer does not elect the employers’ liability coverage. PRISCILLA E. MBU herturnon@gmail.com SELF WAUKEE DALLAS IOWA WINGO SPENCER JOHNSON Signed
2230 2024-05-16 16:15 Anonymous (not verified) 94.188.205.175 Hagerty LLC Proprietorship 2816 Highway 22 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. 2024-05-16 RYAN JOESPH HAGERTY hagertyllc@gmail.com Muscatine IA United States Mary Wetzel Misty Wetzel Signed (1) The employer does not elect the employers’ liability coverage. RYAN JOESPH HAGERTY hagertyllc@gmail.com owner of llc Muscatine IA United States Mary Wetzel Misty Wetzel Signed
2225 2024-05-15 20:43 Anonymous (not verified) 94.188.205.168 Vibrant Supported Community Living WHC Limited Liability Company 1036 66th 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. 2024-05-15 Shinaye Finney-EL Finneyel1973@icloud.com WINDSOR HEIGHTS Iowa United States Shinaye Finney-EL Shinaye Finney-EL Signed (1) The employer does not elect the employers’ liability coverage. Shinaye Finney-EL Finneyel1973@icloud.com Contractor WINDSOR HEIGHTS Iowa United States Shinaye Finney-EL Shinaye Finney-EL Signed
2223 2024-05-14 16:16 Anonymous (not verified) 94.188.205.168 Test Proprietorship test 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. 2024-05-14 Test User aaron.staker@dia.iowa.gov Test Test Test Test Witness Test Witness 2 Signed (1) The employer does not elect the employers’ liability coverage. Testing aaron.staker@dia.iowa.gov Testing Testing Testing Testing Testing Witness 1 Testing Witness 2 Signed
2221 2024-05-13 09:26 Anonymous (not verified) 94.188.207.226 Chad matthews Proprietorship 3000 Justin dr. Suite J 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. 2024-05-13 Chad matthews kaceno2269@gmail.com Urbandale IA United States Sheri Frazier Terry warren Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Chad Matthews kaceno2269@gmail.com None Urbandale IA United States Sheri Fraiser Terry Warren Signed
2219 2024-05-10 10:20 Anonymous (not verified) 94.188.207.228 Froyo To Go, LLC Limited Liability Company 909 4th Ave. South, Denison, Iowa 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. 2024-05-10 Derek Lambert drdereklambert@gmail.com Denison Crawford Iowa Maria Sandoval Nahomy Fernandez Alvarado Signed (1) The employer does not elect the employers’ liability coverage. Trevis Beeck trevis.beeck.u0ms@statefarm.com I am the State Farm Agent who is submitting the Business Policy Denison Crawford Iowa Maria Sandoval Nahomy Fernandez Alvarado Signed
2220 2024-05-10 11:10 Anonymous (not verified) 94.188.207.229 Froyo To Go, LLC Limited Liability Company 909 4th Ave S., Denison, Iowa 51442 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. 2024-05-10 Lucas Gillmor lgillmor@dmuonline.com Denison Crawford Iowa Maria Sandoval Nahomy Fernandez Alvarado Signed (1) The employer does not elect the employers’ liability coverage. Trevis Beeck trevis.beeck.u0ms@statefarm.com State Farm Agent Denison Crawford Iowa Maria Sandoval Nahomy Fernandez Alvarado Signed
2216 2024-05-09 11:51 Anonymous (not verified) 94.188.207.229 Imhoff Innovations LLC Limited Liability Company 108 Cherry Lane Riverside, IA 52327 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. 2024-05-09 Jediah Imhoff jedimhoff@gmail.com Riverside IA United States Jordan Nisiewicz Jordan Lyod Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Regional Recruiter Kansas City Johnson MO Jordan Lyod Jediah Imhoff Signed