1539 |
2023-03-28 16:50 |
Anonymous (not verified) |
94.188.207.230 |
Sulzner Construction LLC |
Limited Liability Company |
210 N CHERRY ST, PO BOX 264 |
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. |
2023-03-28 |
Aksel C Sulzner |
akselsmoke@gmail.com |
Mechanicsville |
IA |
United States |
self |
self |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aksel C Sulzner |
akselsmoke@gmail.com |
Self |
Mechanicsville |
IA |
United States |
self |
self |
Signed |
1543 |
2023-03-29 15:37 |
Anonymous (not verified) |
94.188.207.225 |
Sulzner Construction LLC |
Limited Liability Company |
210 N CHERRY ST, PO BOX 264 |
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. |
2023-03-29 |
Aksel C Sulzner |
akselsmoke@gmail.com |
Mechanicsville |
IA |
United States |
Toni Pollard |
Phil Rouse |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aksel C Sulzner |
akselsmoke@gmail.com |
Self |
Mechanicsville |
IA |
United States |
Toni Pollard |
Phil Rouse |
Signed |
1456 |
2023-02-15 13:12 |
Anonymous (not verified) |
94.188.205.168 |
Bloodgood construction services |
Proprietorship |
4422 happy trail prole ia 50229 |
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. |
2023-02-15 |
Alan Dean bloodgood |
alanbloodgood@gmail.com |
Prole |
Warren |
Ia |
Derek bloodgood |
Albert bloodgood |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bloodgood construction services |
alanbloodgood@gmail.com |
Self |
Prole |
Warren |
Ia |
Derek bloodgood |
Albert bloodgood |
Signed |
1134 |
2022-05-31 09:08 |
Anonymous (not verified) |
65.125.92.130 |
EAC Multi-Services, Inc, |
Proprietorship |
6224 Forest Ave. Des Moines, IA 50311 |
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. |
2022-05-31 |
Alan E Enamordo |
enriqueecalowcare@gmail.com |
Des Moines |
Polk |
Iowa |
Chad Smith |
Adam Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alan E Enamordo |
enriqueecalowcare@gmail.com |
self |
Des Moines |
Polk |
IA |
Chad Smith |
Adam Smith |
Signed |
1166 |
2022-06-23 09:44 |
Anonymous (not verified) |
74.84.106.106 |
alan squires |
Proprietorship |
702 2nd ave sw #4 |
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. |
2022-06-23 |
alan squires |
shanesq411@gmail.comm |
altoona |
polk |
iowa |
TIna Owens |
Rita Littell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
alan squires |
shanesq411@gmail.com |
self |
altoona |
polk |
iowa |
Tina Owens |
Rita Littell |
Signed |
765 |
2021-11-22 16:07 |
Anonymous (not verified) |
63.229.189.35 |
Stahmer Construction |
Proprietorship |
318 Jackson St N Harris IA 51345 |
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. |
2021-11-22 |
Alan Stahmer |
abigail@rickmilesartisans.com |
Harris |
Osceola |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alan Stahmer |
abigail@rickmilesartisans.com |
Self |
Harris |
Osceola |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
87 |
2020-03-11 15:42 |
Anonymous (not verified) |
50.105.78.41 |
Al's Aerial Spraying, LLC |
Limited Liability Company |
3473 N Shepardsville Rd, Ovid MI 48866 |
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. |
2020-03-11 |
Albert Edward Schiffer |
Al400@aol.com |
Ovid |
Cliinton |
Michigan |
Seth Alexander |
Nicholas Crofoot |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Albert Edward Schiffer |
Al400@aol.com |
Boss |
Ovid |
Clinto |
Michigan |
Nicholas Crofoot |
Nicholas Crofoot |
Signed |
1937 |
2023-12-04 17:42 |
Anonymous (not verified) |
94.188.205.174 |
Albert Schwartz |
Proprietorship |
2250 Hwy 1 Sw Kalona, ia 52247 |
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. |
2023-12-04 |
Albert Schwartz |
sageburnner100@msn.com |
Kalona |
Johnson |
Iowa |
Laura Schwartz |
Jackie Etheredge |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Albert Schwartz |
sageburnner100@msn.com |
Myself |
Kalona |
Johnson |
Iowa |
Laura Schwartz |
Jackie Etheredge |
Signed |
487 |
2021-04-20 11:10 |
Anonymous (not verified) |
207.191.193.167 |
Chento Construction |
Proprietorship |
702 Lincoln St. Ainsworth, IA 52201 |
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. |
2021-04-05 |
Alberto Garcia |
chentoconstruction@hotmail.com |
Ainsworth |
Washington |
Iowa |
Anthony Johnson |
Jessica Lopez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alberto Garcia |
chentoconstruction@hotmail.com |
Owner |
Ainsworth |
Washington |
Iowa |
Anthony Johnson |
Jessica Lopez |
Signed |
1724 |
2023-07-06 19:34 |
Anonymous (not verified) |
94.188.207.223 |
ALDO B. CANCINO HERNANDEZ |
Proprietorship |
2524 SHADOW CREEK LN, 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. |
2023-07-06 |
ALDO B. CANCINO HERNANDEZ |
aldo94.cansino@gmail.com |
DES MOINES |
USA |
IOWA |
JUAN M. MAYORGA |
OFELIA BUSTILLOS VALENZUELA |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
ALDO B. CANCINO HERNANDEZ |
aldo94.cancino@gmail.com |
SELF |
DES MOINES |
USA |
IOWA |
JUAN M. MAYORGA |
OFELIA BUSTILLOS VALENZUELA |
Signed |