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Nonelection of Workers' Compensation or Employers' Liability Coverage

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Showing 41 - 50 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:
510 2021-05-10 15:27 Anonymous (not verified) 108.190.5.14 Shift Transport LLC Limited Liability Company 4215 Kris Line Drive 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. 2021-05-10 Adnan Pajazetovic Adoni.shift@gmail.com Waterloo Black Hawk Iowa Fata Pajazetovic Melda Pajazetovic Signed (1) The employer does not elect the employers’ liability coverage. Adnan Pajazetovic adoni.shift@gmail.com Owner Waterloo Black Hawk Iowa Fata Pajazetovic Melda Pajazetovic Signed
929 2022-02-18 09:18 Anonymous (not verified) 174.198.74.217 LA Painting LLC Limited Liability Company 6460 Merle Hay Rd unit 222 Johnston, IA 50131 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. 2022-02-18 Adolfo Rodriguez Afanador adolforodriguez11@yahoo.com Johnston Polk Iowa Esequiel Rodriguez Karina Valdez Signed (1) The employer does not elect the employers’ liability coverage. Adolfo Rodriguez Afanador adolforodriguez11@yahoo.com Owner Johnston Polk Iowa Esequiel Rodriguez Karina Valdez Signed
525 2021-05-18 09:42 Anonymous (not verified) 50.82.130.211 Adrian Bernard Proprietorship 803 Russell Circle, Parkersburg IA 50665 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. 2021-05-07 Adrian Bernard cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Adrian Bernard cmins_re@mchsi.com Self Parkersburg Butler Iowa Chad Campbell Chad Campbell Signed
1863 2023-10-06 12:24 Anonymous (not verified) 94.188.207.223 ADRIAN CAZARES HERNANDEZ Proprietorship 409 N 16TH PL, ESTHERVILLE, IA 51334 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. 2023-10-06 ADRIAN CAZARES HERNANDEZ JOEL@WALKERINSURANCE.COM ESTHERVILLE EMMET IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. ADRIAN CAZARES HERNANDEZ JOEL@WALKERINSURANCEIA.COM SELF ESTHERVILLE EMMET IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
492 2021-04-22 08:33 Anonymous (not verified) 66.188.136.150 Adrian Hackney Proprietorship 1513 7th St. Boone, IA 50036 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. 2021-04-20 Adrian Hackney kschumacher@tricorinsurance.com Boone Boone IA Shuree Behr Mitch Kemp Signed (1) The employer does not elect the employers’ liability coverage. Adrian Hackney kschumacher@tricorinsurance.com Same Boone Boone IA Shuree Behr Mitch Kemp Signed
1927 2023-11-29 13:13 Anonymous (not verified) 94.188.207.228 Yaardman landscaping llc Limited Liability Company 51623 se seet cedar rapids iowa 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. 2023-11-29 Adrian Pink Mr.Pink1118@gmail.com CEDAR RAPIDS IA United States Andrea Parker Kamar James Signed (1) The employer does not elect the employers’ liability coverage. Adrian Pink Mr.Pink1118@gmail.com Owner CEDAR RAPIDS IA United States Andrea Parker Kamar James Signed
1938 2023-12-05 11:54 Anonymous (not verified) 94.188.207.225 Genius automotive Limited Liability Company 51623 se seet cedar rapids iowa 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. 2023-12-05 Adrian Pink Mr.Pink1118@gmail.com CEDAR RAPIDS IA United States Andrea Parker Kamar james Signed (1) The employer does not elect the employers’ liability coverage. Adrian Pink Mr.Pink1118@gmail.com None CEDAR RAPIDS IA United States Andrea Parker Kamar James Signed
1694 2023-06-16 14:37 Anonymous (not verified) 94.188.205.176 Leaf Home Solutions LLC Partnership 3060 SE Grimes Blvd Suite 100-300, 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. 2023-06-16 Caleb Brincks chbrincks@gmail.com 628 NE 56th St Ankeny IA, 50021 Polk County Iowa Melissa Brincks Anisha Moten Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. AFTON INC chbrincks@gmail.com Owner Ankeny Polk Iowa Melissa Brincks Anisha Moten Signed
1718 2023-06-29 12:36 Anonymous (not verified) 94.188.205.166 Aidan Obermueller Proprietorship 2520 N Grandview Avenue, Dubuque, IA 52001 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. 2023-06-27 Aidan Obermueller aidanobermueller@icloud.com Dubuque Dubuque Iowa Brenda Lewis Sue Miller Signed (1) The employer does not elect the employers’ liability coverage. Aidan Obermueller aidanobermueller@icloud.com self Dubuque Dubuque Iowa Brenda Lewis Sue Miler Signed
307 2020-11-04 14:43 Anonymous (not verified) 50.82.130.211 ALL N DESIGNS, LLC Limited Liability Company 601 Nicklaus Drive, Parkersburg IA 50665 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. 2020-10-23 Aimee Allan cmins_re@mchsi.com Parkersburg Butler iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Aimee Allan cmins_re@mchsi.com Self Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed