1155 |
2022-06-14 12:44 |
Anonymous (not verified) |
207.45.82.36 |
GREEN AND SHINE SERVICES INC |
Proprietorship |
210 Ne 41st st Apt 203 Ankeny, IA, 50021 |
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. |
2022-06-14 |
ALEX A. LOPEZ REDONDO |
greenandshineservices@gmail.com |
ankeny |
polk |
iowa |
Giselle roa |
Marta casado |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alex A Lopez Redondo |
greenandshineservices@gmail.com |
propery |
ankeny |
polk |
iowa |
Giselle Roa |
Marta Casado |
Signed |
567 |
2021-07-08 14:22 |
Anonymous (not verified) |
50.82.130.211 |
Black Cat Ice Cream, LLC |
Limited Liability Company |
1031 Office Park Road, Suite #4, West Des Moines IA 50265 |
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. |
2021-06-10 |
Alex Carter |
cmins_re@mchsi.com |
Des Moines |
Polk |
Iowa |
Mary Brown |
Kaytee Stearns |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Black Cat Ice Cream, LLC |
cmins_re@mchsi.com |
Self |
Des Moines |
Polk |
Iowa |
Mary Brown |
Kaytee Stearns |
Signed |
1629 |
2023-05-09 08:50 |
Anonymous (not verified) |
94.188.207.223 |
Alex Jones |
Proprietorship |
2423 Glass Road Northeast, Cedar Rapids, IA 52402, United State |
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. |
2023-05-09 |
Alex Jones |
ajones0425@yahoo.com |
Cedar Rapids |
Linn |
Iowa |
Jordan Nisiewicz |
Charles Wood |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Clay |
Missouri |
Jordan Loyd |
Charles Wood |
Signed |
1794 |
2023-08-10 14:56 |
Anonymous (not verified) |
94.188.205.169 |
Alex Kiler |
Proprietorship |
10511 Main Road, La Porte City, IA 50651, United States |
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. |
2023-08-10 |
Alex Kiler |
alexkiler12622@gmail.com |
La Porte City, IA |
Black Hawk County |
Iowa |
Charles Woods |
Steve Geisler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Clay |
Missouri |
Charles Wood |
Steven Geisler |
Signed |
469 |
2021-04-12 16:49 |
Anonymous (not verified) |
65.103.82.36 |
Stice Construction |
Proprietorship |
13723 140th st W |
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. |
2019-07-22 |
Alex Stice |
Astice17@hotmail.com |
Taylor Ridge |
Rock Island |
IL |
Ashley Stice |
JIm Stice |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alex Stice |
astice17@hotmail.com |
self |
taylor ridge |
rock island |
il |
Ashley stice |
Jim Stice |
Signed |
296 |
2020-10-29 09:39 |
Anonymous (not verified) |
174.243.81.9 |
Alex Vanderbeek |
Proprietorship |
85 NE Grace Wood Drive, 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. |
2020-10-29 |
Alex Vanderbeek |
Vanderbeek17151@gmail.com |
Waukee |
Dallas |
Iowa |
Joe Simpson |
James Nelson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alex Vanderbeek |
Vanderbeek17151@gmail.com |
self |
WAUKEE |
IA |
United States |
Joe Simpson |
James Nelson |
Signed |
1746 |
2023-07-14 09:21 |
Anonymous (not verified) |
94.188.205.176 |
Alex Webb |
Proprietorship |
4019 West Roderweis Road Cabot Ar 72023 |
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. |
2023-07-14 |
Alex Webb |
frankie.webb@yahoo.com |
Cabot |
Pulaski |
Arkansas |
Mark Ellis |
Becky Ellis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ellis Flying Service INC. |
fly@ellisflying.com |
President |
Newport |
Arkansas |
United States |
Alex Webb |
Becky Ellis |
Signed |
452 |
2021-03-26 07:30 |
Anonymous (not verified) |
173.31.109.49 |
Rogers Concrete Construction |
Partnership |
22802 County Rd E34 |
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. |
2021-03-26 |
Alexander Olah |
aolah43@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Robin Marie Kane |
Augies Rodrigez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kevin Johnson |
kevinjohnson@libertymutual.com |
Insurance Agent |
Appleton |
Outagamie |
Wisconsin |
Robin Marie Kane |
Augie Rodrigez |
Signed |
1322 |
2022-09-27 11:31 |
Anonymous (not verified) |
96.31.4.134 |
Owens Inspection Services |
Limited Liability Company |
598 2nd Street SE |
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 |
Alexander Patrick Owe s |
ap_owens_14@yahoo.com |
Hospers |
Sioux |
Iowa |
Michael Vander Wilt |
Shane Meendering |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Donald Patrick Owens |
dpowens@premieronline.net |
Owner |
Sioux Center |
Sioux |
Iowa |
Michael Vander Wilt |
Shane Meendering |
Signed |
1454 |
2023-02-14 09:34 |
Anonymous (not verified) |
94.188.207.227 |
Spencer Imaging Center, LLC |
Limited Liability Company |
710 S. Grand Ave., Spencer, IA 51301 |
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. |
2023-02-14 |
Alexander Pruitt |
apruitt@ncn.net |
Spencer |
Clay |
IA |
Shanna Marie Kooker |
Chad Roemeling |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Muller |
mullerwilliam@hotmail.com |
Co owner |
Spencer |
Clay |
IA |
Shanna Marie Kooker |
Chad Roemeling |
Signed |