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Nonelection of Workers' Compensation or Employers' Liability Coverage

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Showing 1 - 10 of 2196.   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:
405 2021-02-17 11:04 Anonymous (not verified) 104.201.67.178 CYE Painting Limited Liability Company 5202 SE 31st Ct Des Moines,IA 50320 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. 2021-02-17 CYE Painting marilopez9657@yahoo.com Des Moines Polk Iowa Maricela Lopez Cruz Cabrera Signed (1) The employer does not elect the employers’ liability coverage. Maricela Lopez marilopez9657@yahoo.com N/a Des Moines Polk IA Maricela Lopez Cruz Cabrera Signed
61 2020-02-13 08:44 Anonymous (not verified) 71.28.216.94 Cyclone Captioning, Inc Proprietorship 8866 W 122nd Street N, Mingo, IA 50168 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. 2020-02-13 Holli L. Schneider Hlschneid87@gmail.com Mingo Jasper IA Dan Herrin Minda Dearden Signed (1) The employer does not elect the employers’ liability coverage. Holli Schneider hlschneid87@gmail.com President of Proprietorship Mingo Jasper IA Dan Herrin Minda Dearden Signed
1811 2023-08-21 17:03 Anonymous (not verified) 94.188.205.167 Cardinal Concrete LLC Limited Liability Company 503 17th 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. 2023-08-21 Ryan Woods cardinalconcrete.cw@gmail.com Boone Boone Iowa Jon Buller Terry Miles Signed (1) The employer does not elect the employers’ liability coverage. Ryan Woods cardinalconcrete.cw@gmail.com 100% owner Boone Boone Iowa Jon Buller Terry Miles Signed
1530 2023-03-23 16:14 Anonymous (not verified) 94.188.205.166 Los Cousins gutters Limited Liability Company 901 sw 62nd st des moines ia 50312 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. 2023-03-23 Freddy Morales 1981ayoria@gmail.com Des Moines Ia Polk Iowa Denni bazan Dionicio morales Signed (1) The employer does not elect the employers’ liability coverage. Freddy Morales 1981ayoria@gmail.com 1981ayoria@gmail.com Desmoines Polk Ia Dennis Bazan Dionicio Morales Signed
1673 2023-06-02 09:30 Anonymous (not verified) 94.188.207.228 Kacena Family Tree Farm Inc Partnership 2510 55th St., Vinton, IA 52349 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. 2023-06-01 Alyce Lynch kacenafarms.alyce@gmail.com Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed (1) The employer does not elect the employers’ liability coverage. Alyce Lynch ashlyn@3riversins.net 25% Owner - President Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed
1674 2023-06-02 09:34 Anonymous (not verified) 94.188.207.229 Kacena Family Tree Farm Inc Partnership 2510 55th St., Vinton, IA 52349 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. 2023-06-01 Kyle Lynch kacenafarms.alyce@gmail.com Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed (1) The employer does not elect the employers’ liability coverage. Alyce Lynch ashlyn@3riversins.net 25% Owner - President Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed
1675 2023-06-02 09:37 Anonymous (not verified) 94.188.207.228 Kacena Family Tree Farm Inc Partnership 2510 55th St., Vinton, IA 52349 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. 2023-06-01 Kevin Kacena kacenafarms.alyce@gmail.com Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed (1) The employer does not elect the employers’ liability coverage. Alyce Lynch ashlyn@3riversins.net 25% Owner - President Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed
1676 2023-06-02 09:41 Anonymous (not verified) 94.188.207.229 Kacena Family Tree Farm Inc Partnership 2510 55th St., Vinton, IA 52349 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. 2023-06-01 Debra Kacena kacenafarms.alyce@gmail.com Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed (1) The employer does not elect the employers’ liability coverage. Alyce Lynch ashlyn@3riversins.net 25% Owners - President Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed
1819 2023-08-26 00:50 Anonymous (not verified) 94.188.205.177 JnP Enterprise LLC D/B/A/ JnP Trucking Limited Liability Company 110 Elizabeth St W Grand Junction, IA. 50107 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. 2023-08-26 Patrick Cook pat@jnp-enterprise.com Grand Junction Iowa United States Mary J Mack Hayden M Cook Signed (1) The employer does not elect the employers’ liability coverage. Patrick Cook pat@jnp-enterprise.com 50% Member, Owner, Operator Grand Junction Iowa United States Mary J Mack Hayden M Cook Signed
1411 2023-01-06 12:35 Anonymous (not verified) 72.255.93.91 Amayas Painting Proprietorship 1501 Mattern Ave, Des Moines, IA 50316 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. 2022-11-01 Carlos Alexando Amaya Garcia bmoellers@thebookkeepersinc.net Des moines Polk IA Tammy Robbins Gary Cort Signed (1) The employer does not elect the employers’ liability coverage. Brett Moelles bmoellers@thebookkeepersinc.net Accountant Des Moines Polk IA Tammy Robbins Gary Cort Signed