Official State of Iowa Website Here is how you know
Agencies A-Z Programs & Services
  1. Nonelection of Workers' Compensation or Employers' Liability Coverage
  2. Table

Nonelection of Workers' Compensation or Employers' Liability Coverage

Primary tabs

Secondary tabs

Showing 1 - 10 of 2193.   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:
1629 2023-05-09 08:50 Anonymous (not verified) 94.188.207.223 Alex Jones Proprietorship 2423 Glass Road Northeast, Cedar Rapids, IA 52402, United State 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. 2023-05-09 Alex Jones ajones0425@yahoo.com Cedar Rapids Linn Iowa Jordan Nisiewicz Charles Wood Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay Missouri Jordan Loyd Charles Wood Signed
2116 2024-03-27 09:53 Anonymous (not verified) 94.188.205.175 Purdy Pretty Projects inc Proprietorship 5380 13 ave, La porte city, IA 50651, US 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. 2024-03-27 Chad Purdy redtactor12345@gmail.com La porte city LaPorte County Iowa Jordan Nisiewicz Jordan Loyd Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Johnson Missouri Jordan Loyd Warren Crow Signed
1794 2023-08-10 14:56 Anonymous (not verified) 94.188.205.169 Alex Kiler Proprietorship 10511 Main Road, La Porte City, IA 50651, United States 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. 2023-08-10 Alex Kiler alexkiler12622@gmail.com La Porte City, IA Black Hawk County Iowa Charles Woods Steve Geisler Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay Missouri Charles Wood Steven Geisler Signed
1848 2023-09-19 10:20 Anonymous (not verified) 94.188.207.226 Josh Woodworth Proprietorship 16405 u.s. 67 milan il 61264 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. 2023-09-19 Josh woodworth joshwoodworth84@live.com milan Rock island Illinois Cody dunbar Jordan nisiewicz Signed (1) The employer does not elect the employers’ liability coverage. Cody dunbar cdunbar@leaffilter.com Install manager moline Rock island illinois Cody dunbar Jordan nisiewic Signed
1293 2022-09-03 08:03 Anonymous (not verified) 50.82.244.98 MTZ Drywall Proprietorship 1101 Eighth St, West 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. 2022-09-02 Richar Martinez menace_42@icloud.com West Des Moines United States Iowa Alejandro Gonzalez Emilio Martinez Signed (1) The employer does not elect the employers’ liability coverage. Jerry Jenkins jjenkins@farmersagent.com N/A Urbandale United States Iowa Alejandro Gonzalez Emilio Martinez Signed
594 2021-08-03 13:12 Anonymous (not verified) 166.181.80.73 Leaffilter Limited Liability Company 866 40th Ave Bettendorf, IA 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. 2021-08-03 Gerald Landstrum Teamtony710@gmail.com 103 e Grinnell street Gibson Iowa Keokuk Iowa Jake Nagel Ty Reindl Signed (1) The employer does not elect the employers’ liability coverage. LeafFilter Gutter Protection jnagel@leafhome.com assembler Bettendorf Scott Iowa Jake nagel Ty reindl Signed
661 2021-10-01 09:00 Anonymous (not verified) 71.34.184.201 Jose Tavares Proprietorship 1175 Office Park Rd Apt 109 WDM IA 50265 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. 2021-09-24 Jose Tavares deb@piciowa.com 1175 Office Park Rd Apt 109 WDM IA 50266 Polk Iowa Martin Pinon Debra Stratton Signed (1) The employer does not elect the employers’ liability coverage. Jose Tavares deb@piciowa.com self WDM Polk IA Martin Pinon Debra Stratton Signed
1793 2023-08-09 15:23 Anonymous (not verified) 94.188.205.174 Cesar estuardo marroquin gonzalez Proprietorship 1212 David st waterloo 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. 2023-08-09 Cesar estuardo marroquin gonzalez marroquincesar1788@gmail.com 1212 David st waterloo iowa Black haw Iowa Sonia Gomez Sonia Gomez Signed (1) The employer does not elect the employers’ liability coverage. Cesar estuardo marroquin gonzalez marroquincesar1788@gmail.com Patrón 1212 David st waterloo iowa Black hawn Iowa Sonia Gomez Sonia Gomez Signed
771 2021-11-22 20:29 Anonymous (not verified) 75.162.65.250 Art Flooring LLC Limited Liability Company 1225 Emma Ave 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. 2021-11-23 Antonio Rojas artfloorsllc@gmail.com 1225 Emma Ave Polk Iowa Antonio Rojas Hilda Rojas Signed (1) The employer does not elect the employers’ liability coverage. Antonio Rojas artfloorsllc@gmail.com self same as above same as above iowa Antonio Rojas Hilda Rojas Signed
1006 2022-03-25 10:26 Anonymous (not verified) 107.115.239.110 Jesus ojeda Limited Liability Company 866 40th Ave Bettendorf IA 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. 2022-03-25 Jesus Ojeda jesusojeda386@gmail.com 2112 20 1/2 Ave Rock Island 61201 United States Illinois Cody Dunbar Tiffani branham Signed (1) The employer does not elect the employers’ liability coverage. Cody Dunbar cdunbar@leaffilter.com Install manager 866 40th Ave Bettendorf IA 52722 United States Iowa Jordan Nisiewicz Tiffani Branham Signed