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Nonelection of Workers' Compensation or Employers' Liability Coverage

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Showing 11 - 20 of 2228.   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:
328 2020-11-26 12:28 Anonymous (not verified) 174.198.82.38 Duke millwright doing business as duke & sons Limited Liability Company 3264 e Payton ave Des Moines iowa 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. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2020-11-26 Jeremiah duke jpduke24.7.365@gmail.com Des Moines Polk county Iowa Daniel Patrick Hemann Nikki Marie Harvey Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Diana duke dukemillwright@gmail.com Self Des Moines Polk Iowa Nikki Marie Harvey Daniel Patrick Hemann Signed
340 2020-12-18 08:37 Anonymous (not verified) 172.83.31.129 Todd Fisher DBA Lake Country Window Cleaning Proprietorship 1506 Willow Place, 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. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2020-12-18 Todd Fisher Lakecountrywindow@yahoo.com Clear Lake Cerro Gordo Iowa Matt Koch Deb Koch Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Todd Fisher lakecountrywindow@yahoo.com Same Clear Lake Cerro Gordo Iowa Matt Koch Deb Koch Signed
378 2021-01-29 11:43 Anonymous (not verified) 50.82.21.136 GRAPHIX MASTERS Limited Liability Company 420 Hamilton 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. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-01-29 Klayton Karl Kirkpatrick klay@graphixmasters.us Ottumwa IA United States Brian Wilson Aimee Kirkpatrick Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Klayton Kirkpatrick klay@graphixmasters.us Same Ottumwa Iowa United States Brian Wilson Aimee Kirkpatrick 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
426 2021-03-09 09:31 Anonymous (not verified) 50.82.173.179 Joshua Strong DBA Watson Excavation Proprietorship 202 Lewis St Bedford, IA 50833 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. 2021-03-09 Joshua Strong joshandtanyastrong@yahoo.com Bedford Taylor IA Maggie Jackson Shella Baldwin Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Tanya Strong tanya@farmandhomellc.com Spouse Bedford IA United States Maggie Jackson Shella Baldwin Signed
441 2021-03-18 16:20 Anonymous (not verified) 173.25.156.33 CYALCO AVIATION LLC Limited Liability Company 3710 W. MILWAUKEE ST, SPENCER, IA 51301 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. 2021-03-18 WILLIAM A. VAN LENT bvl@veridian.net WEST DES MOINES POLK IOWA ERIN MONFORT NELSON COLE M. VAN LENT Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. WILLIAM A. VAN LENT bvl@veridian.net SAME WEST DES MOINES POLK IOWA ERIN MONFORT NELSON COLE M. VAN LENT Signed
470 2021-04-13 09:34 Anonymous (not verified) 173.21.135.56 JNZ Recruiting LLC Limited Liability Company 703 Washington St. Williamsburg, IA 52361 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. 2021-04-07 Javier Nevarez amanda@burginsuranceagency.com Williamsburg IA IA Amanda Clubb Bradley Schaefer Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Javier Nevarez amanda@burginsuranceagency.com Self Williamsburg Iowa Iowa Amanda Clubb Bradley Schaefer Signed
476 2021-04-13 19:23 Anonymous (not verified) 173.31.147.225 COAST TO COAST MILLWRIGHT LLC Limited Liability Company 2909 HWY 71 AND 9 SPIRIT LAKE, IA 51360 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. 2021-04-05 ADALBERTO CANTU JOEL@WALKERINSURANCEIA.COM SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. ADALBERTO CANTU janiecantu433@outlook.com SELF-MEMBER SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
502 2021-05-04 12:56 Anonymous (not verified) 75.89.78.95 HENNICK TREE SERVICE LLC Limited Liability Company 1852 MAINE RIDGE ROAD, CENTRAL CITY, IA 52214 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. 2021-05-04 BRANDON ALAN HENNICK hennicktreeservice@gmail.com CENTRAL CITY LINN IOWA KATHY RUTH WOOD ROBBIE WILLIAM WILLIS Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Brandon Hennick hennicktreeservice@gmail.com OWNER CENTRAL CITY IA United States KATHY RUTH WOOD ROBBIE WILLIAM WILLIS Signed
546 2021-06-22 15:41 Anonymous (not verified) 208.95.1.97 BAJ FLOORING, LLC Limited Liability Company 31533 CASTLE COURT, DYERSVILLE, IA. 52040 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. 2021-06-11 BRIAN JACQUE jacquebrian18@gmail.com DYERSVIILLE DUBUQUE IOWA STEPHEN J. SCHLUETER PAULA FITZGERALD Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. BRIAN JACQUE jacquebrian18@gmail.com LLC MEMBER DYSERSVILLE DUBUQUE IOWA STEPHEN J. SCHLUETER PAULA FITZGERALD Signed