975 |
2022-03-15 10:34 |
Anonymous (not verified) |
209.152.77.101 |
Bart Fuller & James Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln ST., Ruthven, IA 51358 |
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. |
2022-03-15 |
Bart Fuller |
goffins@ruthventel.com |
Ruthven |
Palo Alto |
Iowa |
Louise Helmke |
Janice Henningsen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bart Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
Palo Alto |
Iowa |
Louise Helmke |
Janice Henningsen |
Signed |
1816 |
2023-08-23 14:59 |
Anonymous (not verified) |
94.188.207.227 |
CHRIS PIERCE CONSTRUCTION LLC |
Proprietorship |
500 N 8th StAkron, IA 5100 |
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. |
2023-08-23 |
Chris Pierce |
chrispierceconstructionllc@gmail.com |
Akron |
Plymouth |
IA |
Susan Geist |
Paychex Insurance Agency |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Susan Geist |
sgeist@paychex.com |
Insurance Agency |
Rochester |
Monroe |
NY |
Susan Geist |
Paychex Insurance Agency |
Signed |
448 |
2021-03-25 10:18 |
Anonymous (not verified) |
172.58.83.161 |
|
Limited Liability Company |
201 Ne 44th St , Apt 111 |
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. |
2021-03-25 |
Aldo Monroy reyes |
Aldogmonroy@gmail.com |
Ankeny |
Polk county |
IOWA |
Elizabeth lopez |
Brayan monroy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aldo Monroy |
Aldogmonroy@gmail.com |
None |
Ankeny |
Polk county |
IOWA |
Aldo Monroy |
Brayan monroy |
Signed |
367 |
2021-01-21 14:18 |
Anonymous (not verified) |
107.117.168.117 |
1105 Wade St |
Proprietorship |
1105 WADE ST |
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. |
2021-01-03 |
Jose J Castillo |
Jonathancas782@gmail.com |
DES MOINES |
IA |
United States |
Jose gaytan |
Ruben lopez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose J Castillo |
Jonathancas782@gmail.com |
Owner |
DES MOINES |
IA |
United States |
Jose gaytan |
Ruben lopez |
Signed |
114 |
2020-04-08 10:51 |
Anonymous (not verified) |
167.142.107.216 |
1959 |
Proprietorship |
601 Country Club 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. |
2020-03-23 |
Timothy Alan Pottebaum |
tpottebaum@nethtc.net |
SHELDON |
O'Brien |
Iowa |
Jill Boerta |
Kris Schoo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy Alan Pottebaum |
tpottebaum@nethtc.net |
owner |
SHELDON |
O'brien |
Iowa |
Jill Boerta |
Kris Schoo |
Signed |
1183 |
2022-07-06 13:43 |
Anonymous (not verified) |
50.82.95.247 |
2DL Construction, LLC |
Limited Liability Company |
1134 21st Street, 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. |
2022-07-06 |
Diego Lopez |
calihernandez01@icloud.com |
Des Moines |
Polk |
Iowa |
Ryan Johnson |
Deanna Yersin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Diego Lopez |
calihernandez01@icloud.com |
Self |
Des Moines |
Polk |
Iowa |
Ryan Johnson |
Deanna Yersin |
Signed |
930 |
2022-02-20 13:24 |
Anonymous (not verified) |
174.198.77.72 |
2Maros Excavating Company |
Limited Liability Company |
204 West First Street, Saint Donatus, Iowa 52071 |
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. |
2022-02-20 |
Steve Maro |
2marosmfg@gmail.com |
Saint Donatus |
Jackson |
Iowa |
Brenda McKenna |
Joe McKenna |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steve Maro |
2marosmfg@gmail.com |
Owner |
Saint Donatus |
Jackson |
Iowa |
Brenda McKenna |
Joe McKenna |
Signed |
1194 |
2022-07-08 13:12 |
Anonymous (not verified) |
174.45.15.103 |
307 Safety LLC |
Limited Liability Company |
9 Trinidad CT Gillette, WY 82716 |
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. |
2022-07-08 |
Joshua Peter Tompkins |
JTompkins@307Safety.com |
Gillette |
Campbell |
Wyoming |
Paul Prather |
Jason Praus |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua Peter Tompkins |
JTompkins@307Safety.com |
Owner |
Gillette |
Campbell |
Wyoming |
Paul Prather |
Jason Praus |
Signed |
608 |
2021-08-17 21:35 |
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 |
James D VanderBeek |
jvanderbeek@plbci.com |
New Sharon |
Mahaska |
IA |
Barbara M VanderBeek |
Zackery James VanderBeek |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Barbara M VanderBeek |
bvanderbeek33z@gmail.com |
Spouse |
New Sharon |
Mahaska |
IA |
James D VanderBeek |
Zackery J VanderBeek |
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 |