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Nonelection of Workers' Compensation or Employers' Liability Coverage

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# 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:
297 2020-10-30 10:43 Anonymous (not verified) 216.51.132.207 Kregel Farm Partnership Limited Liability Partnership 30392 Garber RD Guttenberg, IA 52052 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. 2020-09-08 Travis Kregel TRAVIS.KREGEL@GMAIL.COM Garber Clayton Iowa Jerry J Rochford Nicole L Parker Signed (1) The employer does not elect the employers’ liability coverage. Travis Kregel TRAVIS.KREGEL@GMAIL.COM owner Guttenberg Clayton Iowa Jerry J Rochford Nicole L Parker Signed
298 2020-10-30 10:45 Anonymous (not verified) 216.51.132.207 Kregel Farm Partnership LLP Limited Liability Partnership 30392 Garber RD Guttenberg, IA 52052 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. 2020-09-08 Gary Kregel TRAVIS.KREGEL@GMAIL.COM Guttenberg Clayton Iowa Jerry J Rochford Nicole L Parker Signed (1) The employer does not elect the employers’ liability coverage. Gary Kregel TRAVIS.KREGEL@GMAIL.COM same Guttenberg Clayton Iowa Jerry J Rochford Nicole L Parker Signed
299 2020-10-30 10:47 Anonymous (not verified) 216.51.132.207 Kregel Farm Partnership LLP Limited Liability Partnership 30392 Garber RD Guttenberg, IA 52052 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. 2020-09-09 Darlene Kregel TRAVIS.KREGEL@GMAIL.COM Guttenberg Clayton Iowa Jerry J Rochford Nicole L Parker Signed (1) The employer does not elect the employers’ liability coverage. Darlene Kregel TRAVIS.KREGEL@GMAIL.COM owner Guttenberg Clayton Iowa Jerry J Rochford Nicole L Parker Signed
1105 2022-05-16 13:40 Anonymous (not verified) 174.235.192.160 Travis Montgomery Trucking LLC Limited Liability Company 701 N 4th street Plainview Ne 68769 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. 2022-05-16 Travis Montgomery travismontgomery76@gmail.com Plainview Pierce Nebraska Tim Woslager Trent Montgomery Signed (1) The employer does not elect the employers’ liability coverage. Travis Montgomery Trucking LLC travismotgomery76@gmail.com Owner Plainview Pierce Nebraska Trent Montgomery Tim woslager Signed
1106 2022-05-16 13:40 Anonymous (not verified) 174.235.192.160 Travis Montgomery Trucking LLC Limited Liability Company 701 N 4th street Plainview Ne 68769 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. 2022-05-16 Travis Montgomery travismontgomery76@gmail.com Plainview Pierce Nebraska Tim Woslager Trent Montgomery Signed (1) The employer does not elect the employers’ liability coverage. Travis Montgomery Trucking LLC travismotgomery76@gmail.com Owner Plainview Pierce Nebraska Trent Montgomery Tim woslager Signed
1787 2023-08-07 13:15 Anonymous (not verified) 94.188.205.177 Dryseal Roofing and Construction Proprietorship 390 olive st. Martensdale, Iowa 50160 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. 2023-08-07 Travis w. Tibbits travistibbits@yahoo.com Martensdake Warren Iowa Dawn Marie tibbits Chad David walker Signed (1) The employer does not elect the employers’ liability coverage. Travis Wayne Tibbits travistibbits@yahoo.com Self Martensdale Warren Iowa Dawn Marie Tibbits Chad David walker Signed
1031 2022-04-05 06:47 Anonymous (not verified) 172.58.83.170 Aaron Soboroff Limited Liability Company 1617 w George Washington Blvd Davenport Iowa 52804 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. 2022-04-05 Aaron P Soboroff Treedr47@gmail.com Davenport Scott Iowa Amanda Isenberg Josh Strother Signed (1) The employer does not elect the employers’ liability coverage. Aaron P Soboroff Treedr47@gmail.com Owner Always Mowing Davenport Scott Iowa Amanda Isenberg Josh Strother Signed
940 2022-03-01 11:08 Anonymous (not verified) 216.51.251.31 trent montgomery trucking llc Limited Liability Company 1432 eagle ridge circle pierce ne 68767 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. 2022-03-01 trent montgomery trent.montgomery7@gmail.com pierce pierce nebraska warren montgomery travis montgomery Signed (1) The employer does not elect the employers’ liability coverage. trent montgomery trent.montgomery7@gmail.com self pierce pierce nebraska warren douglas montgomery travis warren montgomery Signed
2201 2024-05-06 10:42 Anonymous (not verified) 94.188.207.226 Trent Hatlen Proprietorship 1042 490th Street, Rembrandt, IA 50576 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. 2024-05-06 Trent Hatlen trentgotti@yahoo.com Rembrandt Buena Vista Iowa Jared Brashears Katie Gunkelman Signed (1) The employer does not elect the employers’ liability coverage. Trent Hatlen trentgotti@yahoo.com Owner Rembrandt Buena Vista Iowa Jared Brashears Katie Gunkelman Signed
2219 2024-05-10 10:20 Anonymous (not verified) 94.188.207.228 Froyo To Go, LLC Limited Liability Company 909 4th Ave. South, Denison, 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. 2024-05-10 Derek Lambert drdereklambert@gmail.com Denison Crawford Iowa Maria Sandoval Nahomy Fernandez Alvarado Signed (1) The employer does not elect the employers’ liability coverage. Trevis Beeck trevis.beeck.u0ms@statefarm.com I am the State Farm Agent who is submitting the Business Policy Denison Crawford Iowa Maria Sandoval Nahomy Fernandez Alvarado Signed