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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:
1067 2022-04-23 11:17 Anonymous (not verified) 166.181.82.231 Black Squirrel Siding LLC. Limited Liability Partnership 1512 north 1st ave 203s 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. 2022-04-23 Robby Bartosh zodzoey19@gmail.com Cedar Rapids IA United States Phoenix Bartosh Elijah Irish Signed (1) The employer does not elect the employers’ liability coverage. Jeremiah Petsche Blacksquirrelsiding@gmail.com business partner coralville johnson iowa Phoenix Bartosh Elijah Irish Signed
1804 2023-08-16 18:22 Anonymous (not verified) 94.188.207.226 Zach Moyle Masonry Limited Liability Company 7222 Great River Rd 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. 2023-08-16 Zach Moyle zmoylemasonry@gmail.com Clermont FAYETTE FAYETTE Brittney Loyd Dave Moyle Signed (1) The employer does not elect the employers’ liability coverage. Zach Moyle zmoylemasonry@gmail.com Self Clermont FAYETTE FAYETTE Brittney Loyd Dave Moyle Signed
331 2020-12-03 10:19 Anonymous (not verified) 174.213.165.124 TTC Cleaning Services Limited Liability Company 2155-230th St Marshalltown, IA. 50158 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. 2020-12-03 Zachary Stephen Bolar zbolar80@gmail.com Marshalltown Marshall IA Brian Mason Casey Jesina Signed (1) The employer does not elect the employers’ liability coverage. Zachary Stephen Bolar zbolar80@gmail.com Self Marshall Marshall IA Brian Mason Casey Jesina Signed
730 2021-11-08 14:58 Anonymous (not verified) 97.64.139.42 JZ INC Limited Liability Company 2509 Ne 10th CT Grimes Iowa 50111 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. 2022-11-08 James Zastrow Zastrow74@gmail.com Grimes Iowa United States Kevan Wiggins Jeremy Holmes Signed (1) The employer does not elect the employers’ liability coverage. James Zastrow zastrow74@gmail.com Self grimes polk iowa Kevan Wiggins Jeremy Holmes Signed
784 2021-12-09 09:03 Anonymous (not verified) 97.64.139.42 JZ INC Limited Liability Company 2509 Ne 10th CT Grimes Iowa 50111 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. 2021-12-08 James Scott Zastrow Zastrow74@gmail.com Grimes IA United States NIcole Zastrow Kevan Wiggins Signed (1) The employer does not elect the employers’ liability coverage. James scott Zastrow loffredon@aol.com Self Grimes IA United States nicole zastrow Kevan wiggins Signed
2118 2024-03-27 13:25 Anonymous (not verified) 94.188.207.223 Zaragoza Home Solutions LLC Limited Liability Company 1644 E Walnut St. Des Moines IA 50316 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. 2024-03-27 Roberto C. Curiel zaragozahomesolutionsllc@gmail.com Des Moines Polk Iowa Fabiola Palomares Recendiz Francisco A Palomares Zepeda Signed (1) The employer does not elect the employers’ liability coverage. Roberto C Curiel zaragozahomesolutionsllc@gmail.com Self Des Moines Polk Iowa Fabiola Palomares Recendiz Francisco A Palomares Zepeda Signed
609 2021-08-17 21:42 Anonymous (not verified) 50.82.65.174 33z Racing, LLC Limited Liability Company 307 N Park Ave, New Sharon, IA. 50207 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. 2021-08-17 Zackery James VanderBeek zackvanderbeek@gmail.com New Sharon Mahaska IA Barbara M VanderBeek James. VanderBeek Signed (1) The employer does not elect the employers’ liability coverage. Barbara M VanderBeek bvanderbeek33z@gmail.com Mother New Sharon Mahaska IA James D VanderBeek Barbara M VanderBeek Signed
613 2021-08-19 21:54 Anonymous (not verified) 50.82.65.174 33z Racing, LLC Limited Liability Company 307 N Park Ave, New Sharon, Iowa 50207 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. 2021-08-20 Zackery J VanderBeek zackvanderbeek@gmail.com New Sharon Mahaska IA Margaret Ratcliff Billy Blake Signed (1) The employer does not elect the employers’ liability coverage. Barbara M VanderBeek bvanderbeek33z@gmail.com Mother New Sharon Mahaska IA Margaret Ratcliff Billy Blake Signed
1158 2022-06-17 06:34 Anonymous (not verified) 97.125.255.177 Zach Ellis Proprietorship 3013 Se Stoneridge St Grimes ia 50111 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. 2022-06-17 Zachary Ellis zach2865@gmail.com Grimes IA United States Brittany Klien Kennedy Ellis Signed (1) The employer does not elect the employers’ liability coverage. Zachary Ellis zach2865@gmail.com Myself Grimes Polk Iowa Brittany Klien Kennedy Ellis Signed
2143 2024-04-09 13:05 Anonymous (not verified) 94.188.207.230 CO2 Refrigeration Systems (Iowa) LLC Limited Liability Company 315 E 5th St Ste 202, Waterloo, IA 50703 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. 2024-04-09 Zachary Heintz Laws zach.laws@co2refsystems.com Marshalltown Marshall Iowa Robert E Shomo Steven M Madsen Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Zachary Heintz Laws zach.laws@co2refsystems.com Self Marshalltown Marshall Iowa Robert E Shomo Steven M Madsen Signed