211 |
2020-07-20 15:30 |
Anonymous (not verified) |
138.43.237.249 |
High Caliber Fiber |
Limited Liability Company |
2958 110th Ave Masonville IA 50654 |
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. |
2020-07-20 |
Chris |
Chris_cooepr@highcaliberfiber.com |
masonville |
Delaware |
IA |
NIck Beranek |
Nicole KIntzle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chris Cooper |
Chris_cooper@highcaliberfiber.com |
Self |
Masonville |
Delaware |
IA |
Nick Beranek |
Nicole Kintzle |
Signed |
2131 |
2024-04-02 10:28 |
Anonymous (not verified) |
94.188.205.168 |
Driskell Spray, LLC |
Limited Liability Company |
1279 300th Ave Sidney, IA 51652 |
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. |
2024-03-22 |
Jamie Driskell |
driskell216@gmail.com |
Sidney |
Fremont |
Iowa |
Melinda Goy |
Rhett Goy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jamie Driskell |
driskell216@gmail.com |
owner |
Sidney |
Fremont |
Iowa |
Melinda Goy |
Rhett Goy |
Signed |
185 |
2020-06-12 14:50 |
Anonymous (not verified) |
173.28.28.57 |
Aaron & Eliesa Thomas |
Partnership |
706 3rd Avenue, Parkersburg IA 50665 |
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. |
2020-05-20 |
Aaron & Eliesa Thomas |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aaron & Eliesa Thomas |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
1358 |
2022-11-03 23:03 |
Anonymous (not verified) |
172.86.32.251 |
LeafFilter North LLC |
Limited Liability Company |
1020 James Drive Suite A | Hartland, WI 53209 |
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. |
2022-11-03 |
Aaron Bensinger |
guttershereandnow@outlook.com |
Marion |
Linn |
Iowa |
Silvena Cammareri |
Aaron Bensinger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aaron Bensinger |
guttershereandnow@outlook.com |
Self |
Marion |
Linn |
Iowa |
Aaron Bensinger |
Silvena Cammareri |
Signed |
630 |
2021-09-01 19:29 |
Anonymous (not verified) |
97.125.133.79 |
Aaron J. Rosenbaum |
Proprietorship |
2005 Pine St, Granger, IA 50109 |
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. |
2021-09-01 |
Aaron J. Rosenbaum |
aabaum7@gmail.com |
Granger |
Dallas |
Iowa |
Bruce Klinkenberg |
Trudy Rosenbaum |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aaron Rosenbaum |
aabaum7@gmail.com |
self |
Granger |
Dallas |
Iowa |
Bruce Klinkenberg |
Trudy Rosenbaum |
Signed |
1382 |
2022-12-07 14:40 |
Anonymous (not verified) |
96.31.1.206 |
IGL RENTAL LLC |
Limited Liability Company |
PO BOX 317 |
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. |
2022-10-25 |
AARON JONES |
STAYBOJI@GMAIL.COM |
ARNOLDS PARK |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
AARON JONES |
STAYBOJI@GMAIL.COM |
SELF |
ARNOLDS PARK |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
376 |
2021-01-26 11:14 |
Anonymous (not verified) |
173.28.210.45 |
Cross Medical Lab, L.L.P |
Limited Liability Partnership |
500 E Market St Iowa City IA 52240 |
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. |
2021-01-26 |
Aaron Klein |
lhavel_23@gmail.com |
Iowa City |
Johnson |
Iowa |
Ashley Lee |
Dan Wegman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lori Havel |
lhavel_23@gmail.com |
Office Manager |
Iowa CIty |
Johnson |
IA |
Ashley Lee |
Dan Wegman |
Signed |
561 |
2021-07-08 09:11 |
Anonymous (not verified) |
66.188.136.150 |
Aaron Maldonado dba ATM Trucking |
Proprietorship |
1011 Reynolds Drive, Charleston, IL 61920 |
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. |
2021-07-07 |
Aaron Maldonado dba ATM Trucking |
kschumacher@tricorinsurance.com |
Charleston |
Coles |
IL |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aaron Maldonado dba ATM Trucking |
kschumacher@tricorinsurance.com |
Same |
Charleston |
Coles |
IL |
Mitch Kemp |
Shuree Behr |
Signed |
230 |
2020-08-13 16:59 |
Anonymous (not verified) |
174.217.21.76 |
Aaron Gilbert |
Proprietorship |
11864 W 125th St S, Runnells, IA 50237 |
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. |
2020-08-13 |
Aaron Michael Gilbert |
gilbertinpc@msn.com |
Runnells |
Jasper |
Iowa |
Bob Coluzzi |
Mitch Coluzzi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aaron Michael Gilbert |
gilbertinpc@msn.com |
Same person |
Runnells |
Jasper |
Iowa |
Bob Coluzzi |
Mitch Coluzzi |
Signed |
1031 |
2022-04-05 06:47 |
Anonymous (not verified) |
172.58.83.170 |
Aaron Soboroff |
Limited Liability Company |
1617 w George Washington Blvd Davenport Iowa 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. |
2022-04-05 |
Aaron P Soboroff |
Treedr47@gmail.com |
Davenport |
Scott |
Iowa |
Amanda Isenberg |
Josh Strother |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aaron P Soboroff |
Treedr47@gmail.com |
Owner Always Mowing |
Davenport |
Scott |
Iowa |
Amanda Isenberg |
Josh Strother |
Signed |