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Nonelection of Workers' Compensation or Employers' Liability Coverage

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Showing 2181 - 2190 of 2222.   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:
176 2020-06-07 08:23 Anonymous (not verified) 174.16.51.128 TrueFood LLC Limited Liability Company 2055 Nature Ave Stanton IA 51573 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. 2020-04-24 Brian Barkman brian.barkman@truefood.farm Georgetown Williamson Texas Wanda Barkman Chelsea Church Signed (1) The employer does not elect the employers’ liability coverage. Brian Barkman brian.barkman@truefood.farm TrueFood LLC is owned by agent Stanton Montgomery IA Wanda Barkman Chelsea Church Signed
610 2021-08-18 11:15 Anonymous (not verified) 172.58.84.99 LeafFilter North LLC Partnership 866 40th ave bettendorf iowa 52722 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. 2021-08-18 Thomas R Fuller tomstl001@yahoo.com DAVENPORT Iowa Iowa Bob phillips Julie fuller Signed (1) The employer does not elect the employers’ liability coverage. Jordan nisiewicz jnisiewicz@leafhome.com Regional field recruiter Bettendorf iowa Scott Iowa Warren crow Jordan lloyd 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
1952 2023-12-12 13:26 Anonymous (not verified) 94.188.205.167 Austin Albin Proprietorship 2263 Railroad Street, Jacksonville, IL 62650 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. 2023-11-23 Austin R Albin albinaustin12@gmail.com Jacksonville Morgan IL Wayne Albin Jerry Roth Signed (1) The employer does not elect the employers’ liability coverage. Austin R Albin albinaustin12@gmail.com Self Jacksonville Morgan IL Wayne Albin Jerry Roth Signed
1934 2023-12-01 22:43 Anonymous (not verified) 94.188.207.224 wasabi johnston llc Limited Liability Company 7115 ridgedale ct, 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. 2023-12-01 wenhui chen michaelchen@wasabidsm.com johnston polk Iowa wen Zheng Jenna Yu Signed (1) The employer does not elect the employers’ liability coverage. wenhui chen michaelchen@wasabidsm.com owner johnston polk IOWA wen zheng Jenna Yu Signed
603 2021-08-14 09:39 Anonymous (not verified) 173.20.168.51 Leaf Filter Proprietorship 3060 Southeast Grimes Boulevard 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. 2021-08-14 Francisco Salgado fsalgado1989@gmail.com Perry IA United States Wendy Asturias Susana Romero Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Leaf Filter macosta@leafhome.com none Grimes Polk Iowa Wendy Asturias Susana Romero Signed
413 2021-02-24 16:21 Anonymous (not verified) 199.120.93.40 Nelson Tire Recycling LLC Limited Liability Company 2270 Farley Rd Cascade Iowa 52033 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. 2021-02-24 Richard A Nelson nelsontirerecycling@gmail.com Cascade Dubugue Iowa Wendy Bergfeld Jan Elhinger Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Richard nelsontirerecycling@gmail.com Owner/officer Cascade Dubugue Iowa Wendy Bergfeld Jan Ehlinger Signed
2081 2024-03-08 10:44 Anonymous (not verified) 94.188.205.167 T & S Sandblasting and Painting LLC Limited Liability Company 101 Clinton ST Corwith IA 50430 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. 2024-03-08 Matthew Tindall matt.tindall83@gmail.com Corwith Hancock IA Wendy S Jensen Jason Bradley Signed (1) The employer does not elect the employers’ liability coverage. Matthew Tindall matt.tindall83@gmail.com self Corwith Hancock IA Wendy S Jensen Jason Bradley Signed
2082 2024-03-08 10:47 Anonymous (not verified) 94.188.205.176 T & S Sandblastin and Painting LLC Limited Liability Company 101 Clinton ST Corwith IA 50430 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. 2024-03-08 Robert Schissel matt.tindall83@gmail.com Corwith Hancock Iowa Wendy S Jensen Jason Bradley Signed (1) The employer does not elect the employers’ liability coverage. Robert Schissel matt.tindall83@gmail.com self Corwith Hancock Iowa Wendy S Jensen Jason Bradley Signed
1931 2023-12-01 18:01 Anonymous (not verified) 94.188.207.225 Jay Wang Limited Liability Company 16672 Verona Hills Dr, Clive IA 50325 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. 2023-12-01 Jay Wang jaywang@wasabidsm.com Clive US IA WenHui chen Yingna Zheng Signed (1) The employer does not elect the employers’ liability coverage. Jay Wang Jaywang@wasabidsm.com Self Clive US IA WenHui Chen Yingna Zheng Signed