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Nonelection of Workers' Compensation or Employers' Liability Coverage

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Showing 101 - 110 of 2227.   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:
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
1277 2022-08-22 08:57 Anonymous (not verified) 68.169.247.177 Andrew Betts Proprietorship 305 3rd ave sw cascade 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. 2022-08-22 Andrew Betts dbidrywallco@gmail.com Cascade Dubuque Iowa Jamie manternach Andy hall Signed (1) The employer does not elect the employers’ liability coverage. Andrew Betts dbidrywallco@gmail.com Owner Cascade Iowa United States Jamie manternach Andy hall Signed
453 2021-03-26 08:27 Anonymous (not verified) 192.30.185.142 DYAD LLC Partnership 2308 Summit St, Sioux City, IA 51104 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. 2021-03-26 Andrew Glisar john@kellyconstruction.com Sioux City Woodbury IA Katie Jenks Jenni Ebner Signed (1) The employer does not elect the employers’ liability coverage. Andrew Glisar john@kellyconstruction.com Owner/Partner Sioux City Woodbury IA Katie Jenks Jenni Ebner Signed
456 2021-04-02 10:02 Anonymous (not verified) 207.177.7.191 Goettsch Dispatch Inc Limited Liability Company 200 Main St Galva, IA 51020 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. 2021-03-15 Andrew Goettsch andygoettsch@gmail.com Galva Ida Iowa Kristy Dewey Terri Ullrich Signed (1) The employer does not elect the employers’ liability coverage. Andrew Goettsch andygoettsch@gmail.com President Galva Ida Iowa Kristy Dewey Terri Ullrich Signed
1813 2023-08-22 15:44 Anonymous (not verified) 94.188.205.176 Hart and Company Limited Liability Company PO Box 757 Indianola 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. 2023-08-22 Andrew Hart hartinnovate@gmail.com Ackworth Warren Iowa John M Keller Logan David Signed (1) The employer does not elect the employers’ liability coverage. Andrew Hart hartinnovate@gmail.com Self Ackworth Warren Iowa John M Keller Logan David Signed
1852 2023-09-24 16:02 Anonymous (not verified) 94.188.205.174 Handy Andy Enterprises LLC Limited Liability Company PO Box 479, Williamsburg, Iowa 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. (1) I am not electing the employers’ liability coverage. 2023-01-01 Andrew J Garner andy@handyandyenterprises.net Williamsburg Iowa Iowa Amanda Bowen Kent Pope Signed (1) The employer does not elect the employers’ liability coverage. Andrew J Garner agarner6977@gmail.com Owner Williamsburg Iowa Iowa Amanda Bowen Kent Pope Signed
1651 2023-05-16 22:18 Anonymous (not verified) 94.188.205.175 Corridor Cleaning Services, LLC Limited Liability Company 4621 Orchard Dr NW, Cedar Rapids, Iowa, 52405 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. 2023-06-11 Andrew Kleineck andrew@corridorcleaning.net Cedar Rapids Linn Iowa Cole Smith Suzanne Brue Signed (1) The employer does not elect the employers’ liability coverage. Andrew Kleineck andrew@corridorcleaning.net LLC Member Cedar Rapids Linn Iowa Cole Smith Suzanne Brue Signed