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Nonelection of Workers' Compensation or Employers' Liability Coverage

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Showing 1 - 10 of 2195.   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:
2189 2024-04-29 09:23 Anonymous (not verified) 94.188.207.225 Sals Home Improvements LLC Limited Liability Company 3750 NW Maple Ct Ankeny IA 50023 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. 2024-04-29 Salvador Gomez salvadorg27@hotmail.com Ankeny Polk Iowa Fabiola Palomares Nathan Miller Signed (1) The employer does not elect the employers’ liability coverage. Salvador Gomez salvadorg27@hotmail.com Self Ankeny Polk Iowa Fabiola Palomares Nathan Miller Signed
190 2020-06-19 11:08 Anonymous (not verified) 107.77.207.128 PAT Construction Limited Liability Company 6007 Sw 15th ST 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. 2020-06-21 Pablo Aguilar Tolentino PATConstruction77@gmail.com DES MOINES 77 77 Trisha Resendiz Toni Lopez Signed (1) The employer does not elect the employers’ liability coverage. Pablo Aguilar Tolentino PATconstruction77@gamil.com owner DES MOINES 77 77 Trisha Resendiz Toni Lopez Signed
315 2020-11-13 10:48 Anonymous (not verified) 66.188.136.150 Jessie Spurlin Proprietorship 58977 Al Hwy 77, Talladega, AL 35160 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. 2020-11-11 Jessie Spurlin kschumacher@tricorinsurance.com Talladega Talladega AL Russell Masartis Nancy Wortley Signed (1) The employer does not elect the employers’ liability coverage. Jessie Spurlin kschumacher@tricorinsurance.com Same Talledaga Talledaga AL Russell Masartis Nancy Wortley Signed
538 2021-06-08 16:59 Anonymous (not verified) 66.188.136.150 John Sorrentino Proprietorship 808 Dixie Dr. Enterprise, AL 36330 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. 2021-06-08 John Sorrentino kschumacher@tricorinsurance.com Enterprise Coffee AL Mitch Kemp Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. John Sorrentino kschumacher@tricorinsurance.com Same Enterprise Coffee AL Mitch Kemp Shuree Behr Signed
559 2021-07-08 08:27 Anonymous (not verified) 66.188.136.150 Justin Keplinger Proprietorship 8671 Hamby Rd. Morris, AL 35116 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. 2021-07-07 Justin Keplinger kschumacher@tricorinsurance.com Morris Jefferson AL Mitch Kemp Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Justin Keplinger kschumacher@tricorinsurance.com Same Morris Jefferson AL Mitch Kemp Shuree Behr Signed
1188 2022-07-07 11:24 Anonymous (not verified) 107.117.176.70 Pitts Aerial Services LLC Limited Liability Company 2478 county road 1488 Cullman al 35058 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. 2022-07-07 Austin Branch Pitts pittsaerial@gmail.com Cullman Cullman AL Sydney Pitts James Robertson Signed (1) The employer does not elect the employers’ liability coverage. Austin Branch Pitts pittsaerial@gmail.com Owner Cullman Cullman AL Sydney Pitts James Robertson Signed
1189 2022-07-07 11:50 Anonymous (not verified) 71.91.55.59 Austin Branch Pitts Proprietorship 2478 county road 1488 Cullman al 35058 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. 2022-07-07 Austin Branch Pitts pittsaerial@gmail.com Cullman Cullman AL Sydney Pitts James Robertson Signed (1) The employer does not elect the employers’ liability coverage. Austin Branch Pitts pittsaerial@gmail.com Proprietor Cullman Cullman AL Sydney Pitts James Robertson Signed
537 2021-06-07 15:25 Anonymous (not verified) 66.188.136.150 Casey Young Proprietorship 10731 State Highway 118 Turrell, AR 72384 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. 2021-06-03 Casey Young kschumacher@tricorinsurance.com Turrell Crittenden AR Mitch Kemp Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Casey Young kschumacher@tricorinsurance.com Same Turrell Crittenden AR Mitch Kemp Shuree Behr Signed
1618 2023-04-28 11:10 Anonymous (not verified) 94.188.205.167 Hunter Flying Service, LLC Limited Liability Company PO Box 215 Hunter, AR 72074 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. 2023-04-28 James Lynn Cary hunterflying@att.net Hunter Woodruff Arkansas Karen Gifford Jason White Signed (1) The employer does not elect the employers’ liability coverage. James Lynn Cary hunterflying@att.net Self Hunter Woodruff AR Karen Gifford Jason White Signed
1112 2022-05-17 14:15 Anonymous (not verified) 24.162.40.106 Davis AG Service Texas LLC Limited Liability Company P.O. Box 1475 Fabens, Texas 79838 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. 2022-05-17 John Anthony Davis turbinespacemonkey@yahoo.com Mountain View Stone Arkansas Vicki Lynne Ivey Maggielyn Marie Paul Signed (1) The employer does not elect the employers’ liability coverage. John Anthony Davis turbinespacemonkey@yahoo.com Owner Mountain View Stone Arkansas Vicki Lynne Ivey Maggielyn Marie Paul Signed