658 |
2021-09-27 14:01 |
Anonymous (not verified) |
167.142.136.87 |
Crosser Electric, Inc |
Partnership |
PoBox 204 Eldora, Iowa 50627 |
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. |
2021-09-27 |
Victoria Halvorsen |
vhalvorsen@aol.com |
Eldora |
Hardin |
Iowa |
Laura Kramer |
Melissa Sison |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Victoria or Vicki Halvorsen |
vhalvorsen@aol.com |
Partner sec/treasure |
Eldora |
Hardin |
Iowa |
Laura Kramer |
Melissa Sison |
Signed |
1204 |
2022-07-14 11:59 |
Anonymous (not verified) |
107.1.252.41 |
International Drywall LLC. |
Limited Liability Company |
108 N 4th 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. |
2022-07-14 |
Victoria G Cervantes |
vic8.cervantes@gmail.com |
Marshalltown |
IA |
United States |
Rodrigo Rodriguez |
Juan Cervantes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Victoria G Cervantes |
Vic8.cervantes@gmail.com |
Self |
Marshalltown |
IA |
United States |
Rodrigo Rodriguez |
Juan Cervantes |
Signed |
1809 |
2023-08-21 07:55 |
Anonymous (not verified) |
94.188.207.228 |
Gonzalez Drywall LLC |
Limited Liability Company |
323 Friendhip St Apt 3, Iowa City, IA 52245 |
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. |
2023-08-21 |
Leonel Angel Gonzalez |
victorangel8373@gmail.com |
Iowa City |
Johnson |
Iowa |
Chris Hay |
Brad Bower |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Leonel Angel Gonzalez |
victorangel8373@gmail.com |
Self |
Iowa City |
Johnson |
Iowa |
Chris Hay |
Brad Bower |
Signed |
1810 |
2023-08-21 10:18 |
Anonymous (not verified) |
94.188.207.224 |
Vicente McCain |
Proprietorship |
524 panama st Nashua |
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. |
2023-08-20 |
Jose V Mccain |
Vic_mccain@yahoo.com |
Nashua |
IA |
United States |
Rafael McCain |
Jessica McCain |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jose V Mccain |
Vic_mccain@yahoo.com |
Brother |
Nashua |
IA |
United States |
Rafael McCain |
Jessica McCain |
Signed |
1524 |
2023-03-20 09:00 |
Anonymous (not verified) |
94.188.205.177 |
David Roman |
Proprietorship |
8350 EP True Parkway, Apt 1101, West Des Moines, IA 50266 |
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. |
2023-03-20 |
David Roman |
vida8147@gmail.com |
West Des Moines |
Dallas |
IA |
Dario Lucas Barrera |
Alfonso Montoya |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Roman |
vida8147@gmail.com |
Self |
West Des Moines |
Dallas |
IA |
Dario Lucas Barrera |
Alfonso Montoya |
Signed |
2122 |
2024-03-28 10:15 |
Anonymous (not verified) |
94.188.205.169 |
Stone Villalobos LLC |
Limited Liability Company |
4231 Morton Ave Des Moines Iowa 50317 |
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. |
2024-03-28 |
Josue Villalobos |
villalobosjosue2016@gmail.com |
Des Moines |
Polk |
Iowa |
Edgar Palomares |
Fabiola Palomares Recendiz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josue Villalobos |
villalobosjosue2016@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Edgar Palomares |
Fabiola Palomares Recendiz |
Signed |
1213 |
2022-07-19 14:00 |
Anonymous (not verified) |
198.14.220.143 |
VLG Build & Remodle LLC |
Limited Liability Partnership |
45547 State HWY 14 Chariton, IA 50049 |
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. |
2022-07-19 |
Vladimir Golosinskiy |
VLGCONSTRUCTION@YAHOO.COM |
Chariton |
IA |
United States |
Vladimir Golosinskiy |
Vladimir Golosinskiy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LILIA GOLOSINSKIY |
VLGCONSTRUCTION@YAHOO.COM |
Wife |
CHARITON |
Iowa |
United States |
LILIA GOLOSINSKIY |
LILIA GOLOSINSKIY |
Signed |
698 |
2021-10-28 16:09 |
Anonymous (not verified) |
71.228.88.54 |
Warren Nelson |
Proprietorship |
2525 Nebraska Street, 106, Sioux City, Iowa 51104 |
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. |
2021-10-28 |
Scott D. Nelson |
scottdnelson@hotmail.com |
Sioux City |
Woodbury |
Iowa |
Wallace E Sheets |
Abby McDermott |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Beth L Sheets |
w143bs@verizon.net |
Daughter |
Sarasota |
Manatee |
Florida |
Wallace E. Sheets |
Abby McDermott |
Signed |
322 |
2020-11-17 14:06 |
Anonymous (not verified) |
208.126.118.26 |
Wada Farms |
Limited Liability Company |
2428 270th st Grand Mound, IA 52751 |
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. |
2020-11-17 |
Wade Smith |
wade.smith1110@gmail.com |
Grand Mound |
Clinton |
Iowa |
Megan Fuglsang |
Jenny Gordon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wada Farms |
wade.smith1110@gmail.com |
self |
Grand Mound |
clinton |
Iowa |
Megan Fuglsang |
Jenny Gordon |
Signed |
649 |
2021-09-21 13:15 |
Anonymous (not verified) |
208.126.118.26 |
Wade Smith DBA WADA Farms |
Proprietorship |
2428 270th st, Grand Mound, IA 52751 |
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. |
2021-09-21 |
Wade Smith |
wade.smith1110@gmail.com |
Grand Mound |
Clinton |
Iowa |
Megan Fuglsang |
Jenny Gordon |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Wade Smith |
wade.smith1110@gmail.com |
self |
Grand Mound |
Clinton |
Iowa |
Megan Fuglsang |
Jenny Gordon |
Signed |