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Nonelection of Workers' Compensation or Employers' Liability Coverage

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# 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:
19 2019-12-31 16:29 Anonymous (not verified) 172.58.83.45 A.M. Tile Proprietorship 3824 122nd 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. 2019-12-31 Amar Music amarmusic01@gmail.com Urbandale IA United States Sefik Music Amara Crncevic Signed (1) The employer does not elect the employers’ liability coverage. Amar Music amarmusic01@gmail.com Owner Urbandale IA United States Sefik Music Amara Crncevic Signed
20 2019-12-31 16:36 Anonymous (not verified) 172.58.83.45 A.M. Tile Proprietorship 3824 122nd 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. 2019-12-31 Amar Music amarmusic01@gmail.com Urbandale IA United States Sefik Music Amara Crncevic Signed (1) The employer does not elect the employers’ liability coverage. Omer Okic ultimate.exteriors@gmail.com Owner Des Moines Polk IA Sefik Music Amara Crncevic Signed
191 2020-06-23 16:09 Anonymous (not verified) 173.18.3.76 Look At You LLC Limited Liability Company 5545 Mills Civic Pkwy Ste 100 West Des Moines, 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. 2020-06-23 Amber Keppler keppler_ark@outlook.com Des Moines Polk IA Angela Kinsey Jon Stetzel Signed (1) The employer does not elect the employers’ liability coverage. Amber Keppler keppler_ark@outlook.com LLC Member Des Moines Polk IA Angela Kinsey Jon Stetzel Signed
688 2021-10-25 10:56 Anonymous (not verified) 75.91.173.195 Ami Westcott Proprietorship 2672 F 52 Trail Parnell, IA 52325 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. 2021-10-25 Ami Lynn Westcott ami.westcott@gmail.com Parmell Iowa Iowa Donald Scott Westcott Andrew Patrick Brummel Signed (1) The employer does not elect the employers’ liability coverage. Ami Lynn Westcott ami.westcott@gmail.com self Parnell Iowa Iowa Donald Scott Westcott Andrew Patrick Brummel Signed
1380 2022-11-26 07:41 Anonymous (not verified) 173.17.229.18 M&M Construction LLC Limited Liability Company 32785 Homestead Drive 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. 2022-11-23 Amparo Yamilet Menendez Gonzalez menendez.amparo@yahoo.com Granger Dalles center United States Carla Diaz Jesus Lopez Signed (1) The employer does not elect the employers’ liability coverage. Gerardo Alvarado bariel578@gmail.com Employee Perry IA United States Carla Diaz Jesus lopez Signed
333 2020-12-05 08:57 Anonymous (not verified) 173.25.143.97 Groen Pediatric Consulting Limited Liability Company 1206 NE 31ST ST Ankeny, IA 50021 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. 2021-01-01 Amy Groen dramygroen@yahoo.com Ankeny Iowa United States Daniel Martin Anita Anderson Signed (1) The employer does not elect the employers’ liability coverage. Amy Groen dramygroen@yahoo.com self Ankeny Iowa United States Kay Martin Priscilla Putzier Signed
63 2020-02-17 16:05 Anonymous (not verified) 173.17.12.213 ANA GARCIA GONZALEZ Limited Liability Company 4023 14TH ST DES MOINES IOWA 50313 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. 2020-02-17 Ana Garcia Gonzalez gjeanettegonzalez@gmail.com DES MOINES POLK IOWA LUZ SAUCEDA SANDRA ISABEL SAUCEDA Signed (1) The employer does not elect the employers’ liability coverage. ANA GARCIA GONZALEZ GJEANETTEGONZALEZ@GMAIL.COM SELF DES MOINES POLK IA LUZ SOTELO SAUCEDO SANDRA ISABEL SAUCEDA Signed
1639 2023-05-11 07:39 Anonymous (not verified) 94.188.205.175 JYC Drywall LLC Proprietorship 1034 Grand Ave, Muscatine, IA 52761 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. 2023-05-11 Anastacio Zamarripa 1zama0081@gmail.com Muscatine Louisa Iowa Arcel Servin Chris Hay Signed (1) The employer does not elect the employers’ liability coverage. Anastacio Zamarripa 1zama0081@gmail.com Self Muscatine Louisa Iowa Arcel Servin Chris Hay Signed
1509 2023-03-09 10:39 Anonymous (not verified) 94.188.207.227 Andres Barboza Limited Liability Company 329 West 31 St South Sioux city ne 68776 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. 2023-03-09 Andres Barboza barboza79@yahoo.com South Sioux City Nebraska United States Jaime Gutierrez Gerardo ibarra Signed (1) The employer does not elect the employers’ liability coverage. Andres Barboza barboza79@yahoo.com Owner South Sioux City Nebraska United States Jaime Gutierrez Gerardo ibarra Signed
588 2021-07-27 19:59 Anonymous (not verified) 75.162.226.22 Andres Martinez Limited Liability Company 3903 SW 3rd St. Des Moines, 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. 2021-07-27 Andres Martinez and.am12am@gmail.com Des Moines Polk Iowa Carla Martinez Librado Martinez Signed (1) The employer does not elect the employers’ liability coverage. Andres Martinez and.am12am@gmail.com Employer Des Moines Polk Iowa Carla Martinez Librado Martinez Signed