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  1. Nonelection of Workers' Compensation or Employers' Liability Coverage
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Nonelection of Workers' Compensation or Employers' Liability Coverage

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Showing 31 - 40 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:
1441 2023-02-06 14:37 Anonymous (not verified) 69.40.94.166 ESW CONSTRUCTION INC Partnership 35 HIGHWAY 22, KESWICK IA 50136 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. 2023-02-06 JOSHUA EDMUNDSON payten@iowacropservice.com KESWICK KEOKUK IOWA JULIE WHITE REBECCA APPLEGET Signed (1) The employer does not elect the employers’ liability coverage. BARBARA EDMUNDSON barb@iowacropservice.com agent SIGOURNEY KEOKUK IOWA JULIE WHITE REBECCA APPLEGET Signed
1442 2023-02-06 14:40 Anonymous (not verified) 69.40.94.166 ESW CONSTRUCTION INC Partnership 315 hIGHWAY 22, KESWICK IA 50136 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. 2023-02-06 WENDELL WILEY rtsieren@gmail.com BLOOMFIED DAVIS IOWA JULIE WHITE REBECCA APPLEGET Signed (1) The employer does not elect the employers’ liability coverage. BARBARA EDMUNDSON barb@iowacropservice.com agent SIGOURNEY KEOKUK IOWA JULIE WHITE REBECCA APPLEGET Signed
1448 2023-02-10 16:55 Anonymous (not verified) 94.188.205.177 Marks Nursery LLC Limited Liability Company 15008 310th Trl, Redfield, IA 50233 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. 2023-02-10 Susan L Jones sljoines026@gmail.com Redfield Dallas Iowa Douglas Jones Caitlin Zimmerman Signed (1) The employer does not elect the employers’ liability coverage. Donald Richardson DonR@phillipsassociatesins.net Agent Redfield Dallas Iowa Douglas Zimmerman Caitlin Zimmerman Signed
1499 2023-03-07 11:21 Anonymous (not verified) 94.188.205.177 Ryan Zimmerman Proprietorship 17606 35th St Lime Springs, 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. 2022-04-27 Ryan Zimmerman darrele@ciains.biz Lime Springs Howard Iowa Darrel Elsbernd Chris Fye Signed (1) The employer does not elect the employers’ liability coverage. Darrel Elsbernd darrele@ciains.biz agent Lime Springs Howard Iowa Darrel Elsbernd Chris Fye Signed
1501 2023-03-07 11:27 Anonymous (not verified) 94.188.205.167 Adriene Dangler Proprietorship 2400 South Shore Dr Clear Lake, IA 50428 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. 2022-04-14 Adrienne Dangler darrele@ciains.biz Clear Lake Cerro Gordo Iowa Darrel Elsbernd Chris Fye Signed (1) The employer does not elect the employers’ liability coverage. Darrel Elsbernd darrele@ciains.biz agent Clear Lake Cerro Gordo Iowa Darrel Elsbernd Chris Fye Signed
1503 2023-03-07 12:45 Anonymous (not verified) 94.188.205.177 Al's Roofing LLC Limited Liability Company P O Box 277 Lime Springs, 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. 2022-04-18 John Martin darrele@ciains.biz Lime Springs Howard Iowa Darrel Elsbernd Chris Fye Signed (1) The employer does not elect the employers’ liability coverage. Al's Roofing LLC darrele@ciains.biz agent Lime Springs Howard Iowa Darrel Elsbernd Chris Fye Signed
1729 2023-07-09 15:33 Anonymous (not verified) 94.188.207.223 Melvin A mineros Limited Liability Company 6209 Windsor dr 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. 2023-07-09 Melvin A mineros minerosframing.llc@gmail.com Des moines Polk IA Orlando dominguez Isaac salazar Signed (1) The employer does not elect the employers’ liability coverage. Jaime leiva jaime@boersmaninsurance.com Agent Des moines Polk IA Narciso hidalgo Balmore perez Signed
1775 2023-08-03 09:37 Anonymous (not verified) 94.188.207.227 J j builder llc Limited Liability Company 2307 richland dr des moines ia 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. 2023-07-28 José Cruz Jasso balleza jassoprimo03@icloud.com Des moines Polk Iowa Jaime Rodrigues Mario ramos Signed (1) The employer does not elect the employers’ liability coverage. Irving iibarra@centroinsurance.com Agent Des moines Polk Iowa Irving Ibarra Jaime Rodrigues Signed
1777 2023-08-03 14:21 Anonymous (not verified) 94.188.207.227 Mark Doty Proprietorship 509 Parwood Circle, Huxley, IA 50124 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. 2023-08-03 Mark Doty mdoty@dakotagrown.com Huxley Story IA Rebecca R Moeller Jeffery F Vanasse Signed (1) The employer does not elect the employers’ liability coverage. Rebecca R Moeller Becky@northernlines.net Agent Fairmont MN United States Rebecca R Moeller Jeffery F Vanasse Signed
1778 2023-08-03 14:52 Anonymous (not verified) 94.188.207.227 Melvin A mineros Limited Liability Company 6209 Windsor dr 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. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2023-06-22 Melvin alexander mineros minerosframing.llc@gmail.com Des moines Polk IA Orlando dominguez Isaac salazar Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jaime leiva jaime@boersmaninsurance.com Agent Des moines Polk IA Narciso hidalgo Balmore perez Signed