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Nonelection of Workers' Compensation or Employers' Liability Coverage

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Showing 31 - 40 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:
992 2022-03-21 19:42 Anonymous (not verified) 174.192.66.11 Christopher Binns Proprietorship 1324 Grand Ave, Davenport, IA 52803 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. 2022-03-21 Christopher Binns christophersbinns@gmail.com Davenport Scott IA Adam Coleman Rose Snyder Signed (1) The employer does not elect the employers’ liability coverage. Christopher Binns christophersbinns@gmail.com same Davenport Scott IA Adam Coleman Rose Snyder Signed
2015 2024-02-01 08:26 Anonymous (not verified) 94.188.207.223 Salazar Builders inc Proprietorship 29175 365th st van meter ia 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. 2024-02-01 José Luis ángeles Salazar salazarbuilders15@gmail.com Van meter ia Dallas Iowa Adam Paul Boge Lance Owen Webster Signed (1) The employer does not elect the employers’ liability coverage. Jose Luis angeles Salazar salazarbuilders15@gmail.com Sub contractor Van meter Dallas Iowa Adam Paul Boge Lance Owen Webster Signed
2207 2024-05-07 09:44 Anonymous (not verified) 94.188.207.226 Rodrimart brothers corp Limited Liability Company 958 8th ave nw Altoona 50009 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. 2024-05-07 Enrique Rodriguez carluto_1983@hotmail.com Altoona Polk Iowa Adan boge Lonce wester Signed (1) The employer does not elect the employers’ liability coverage. Enrique Rodriguez carluto_1983@hotmail.com President Altoona Polk Iowa Adan boge Leans wester Signed
2088 2024-03-12 10:44 Anonymous (not verified) 94.188.207.226 Elmer Henry Vicente Lopez Proprietorship 1602 Court St Apt 2 Sioux City, IA 51105 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. 2023-01-01 Elmer Henry Vicente Lopez vicenteelmer33@gmail.com Sioux City Woodbury Iowa Adrian Dominguez Ronald Halverson Signed (1) The employer does not elect the employers’ liability coverage. Ron Halverson ron@sppinsurance.com independent contractor Cherokee Cherokee IA Elmer Henry Vicente Lopez Ronald Halverson Signed
2090 2024-03-12 14:16 Anonymous (not verified) 94.188.205.169 Oscar Sosa Proprietorship 110 E Cherry St Cherokee, IA 51012 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. 2023-01-01 Oscar Sosa oscarsosa@live.com Cherokee Cherokee Iowa Adrian Dominguez Ronald Halverson Signed (1) The employer does not elect the employers’ liability coverage. Ron Halverson ron@sppinsurance.com independent contractor Cherokee Cherokee IA Oscar Sosa Ronald Halverson Signed
232 2020-08-16 11:28 Anonymous (not verified) 173.27.57.39 Landeros & Sons Construction, Inc Limited Liability Partnership 1636 19th Avenue 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. 2020-08-16 Fernando Landeros fland1983@gmail.com Moline Rock Island Illinois Adrian Landeros Emanuel Landeros Signed (1) The employer does not elect the employers’ liability coverage. Emanuel Landeros fland1983@gmail.com Brother Moline Rock Island Illinois Adrian Landeros Emanuel Landeros Signed
522 2021-05-17 20:27 Anonymous (not verified) 50.81.4.25 Crew Cut Lawn Care Limited Liability Company 7820 1st Ave NW Cedar Rapids, IA 52405 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. 2021-05-17 Rupert McKendly Ellis wideglide94@gmail.com Cedar Rapids Linn Iowa Adrian Pink Lorraine Ellis Signed (1) The employer does not elect the employers’ liability coverage. Rupert M Ellis wideglide94@gmail.com Owner Cedar Rapids Linn IA Adrian Pink Lorraine Signed
542 2021-06-16 07:26 Anonymous (not verified) 173.23.202.34 Russell’s lawn & landscape Limited Liability Company 285 robins rd, Hiawatha unit C16 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. 2021-06-16 Johnoy Khalil Russell johnoyjrrussell@gmail.com Hiawatha Linn Iowa Adrian pink Rupert Ellis Signed (1) The employer does not elect the employers’ liability coverage. Johnoy Khalil russell johnoyjrrussell@gmail.com Owner Hiawatha Linn Iowa Rupert ellis Adrian pink Signed
2176 2024-04-24 11:12 Anonymous (not verified) 94.188.205.176 Schutters Pest Control Inc. Limited Liability Company 109 2nd Ave, Suite #2, Carbon Cliff,IL 61239 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. 2024-04-04 Billy Y Schutters schutterspestcontrol@gmail.com Bettendorf Iowa United States Aidan Sammon Kalissa Malin Signed (1) The employer does not elect the employers’ liability coverage. Billy Y Schutters schutterspestcontrol@gmail.com Same Person Carbon Cliff Rock Island Illinois Aidan Sammon Kalissa Malin Signed
1905 2023-11-13 21:35 Anonymous (not verified) 94.188.205.167 Bartolo Lopez Limited Liability Company 2404 cass st Fort Worth tx 76112 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. 2023-11-13 Bartolo Lopez bartololopez3737@gmail.com Fort Worth tx Tarrant county Tx Airan Zamudio Carlos Lopez Signed (1) The employer does not elect the employers’ liability coverage. Bartolo Lopez bartololopez3737@mail.com Boss of the company Fort Worth Tarrant county Texas Airan Zamudio Carlos lopez Signed