791 |
2021-12-14 11:35 |
Anonymous (not verified) |
108.178.194.186 |
Leaf Home solutions LLC |
Limited Liability Company |
1595 Georgetown rd. Hudson OH 44236 |
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. |
2023-12-14 |
Abelardo Lino Montes |
alinomontes@gmail.com |
Le claire IA 52753 |
Scott |
Iowa |
Ann Pelton |
Herman Roche |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Abelardo Lino Montes |
alinomontes@gmail.com |
Owner |
Le Claire |
Scott |
IA |
Ann Pelton |
Herman Roche |
Signed |
646 |
2021-09-20 08:54 |
Anonymous (not verified) |
173.24.107.209 |
QCA Professional Contractors |
Limited Liability Company |
3314 67th Ave, Moline, IL. 61265 |
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. |
2021-09-20 |
Allan Celada |
allancelada@qcaprocontractors.com |
Moline |
Rock Island |
IL |
Alexander Celada |
Drexel Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Allan Celada |
allancelada@qcaprocontractors.com |
self |
Moline |
Rock Island |
IL |
Alexander Celada |
Drexel Miller |
Signed |
39 |
2020-01-19 11:00 |
Anonymous (not verified) |
75.163.84.145 |
Allen L Bryen |
Proprietorship |
2609 Madison St Bellevue NE 68005 |
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. |
2020-01-19 |
Allen Lee Bryen |
Allen.Bryen@yahoo.com |
Bellevue |
Sarpy |
Nebraska |
Jeffrey Coats |
Donald Coats |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Allen L Bryen |
Allen.Bryen@yahoo.com |
Self |
Bellevue |
Sarpy |
Nebraska |
jeffrey Coats |
Donald Coats |
Signed |
2096 |
2024-03-14 14:53 |
Anonymous (not verified) |
94.188.205.168 |
Scott Allen |
Proprietorship |
2603 Bryant Blvd SW |
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. |
2024-03-14 |
Scott Michael Allen |
allen.scottm@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Daniel Bryant Bliek |
Jennifer Lee Allen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Scott Michael Allen |
allen.scottm@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Daniel Bryant Bliek |
Jennifer Lee Allen |
Signed |
57 |
2020-02-10 15:33 |
Anonymous (not verified) |
198.167.182.164 |
AllEnhancements LLC |
Limited Liability Company |
1122 Woodland Ln, LeClaire, IA 52753 |
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. |
2020-01-31 |
Brett Allen |
allenhancementsllc@outlook.com |
LeClaire |
Scott |
Iowa |
Steven J Fishman |
E Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brett Allen |
allenhancementsllc@outlook.com |
Managing Member |
LeClaire |
Scott |
Iowa |
Steven J Fishman |
E Dyan Kriener |
Signed |
112 |
2020-04-07 12:16 |
Anonymous (not verified) |
173.27.33.108 |
Josh Alley Siding |
Proprietorship |
205 N Oak St. Davis City, IA 50065 |
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. |
2018-04-10 |
Joshua H. Alley |
alley.josh@yahoo.com |
Davis City |
Decatur |
Iowa |
Joe Fitzgerald |
Steve Young |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Alley Siding |
alley.josh@yahoo.com |
Owner |
Davis City |
Decatur |
Iowa |
Joe Fitzgerald |
Steve Young |
Signed |
1688 |
2023-06-13 09:29 |
Anonymous (not verified) |
94.188.207.228 |
Ron Burbach |
Proprietorship |
7760 commerce park Dubuque Iowa 52002 |
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. |
2023-06-13 |
Ronald V Burbach |
allgreenron@msn.com |
Dubuque |
Dubuqie |
Iowa |
Mia Burnach |
Jerry david |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ronald V Burbach |
allgreenron@man.com |
Same |
Dubuque |
Dubuque |
Iowa |
Mia F Burbach |
Jerry David |
Signed |
1561 |
2023-04-10 07:35 |
Anonymous (not verified) |
94.188.207.227 |
All season gutter |
Limited Liability Company |
1790 187th street |
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. |
2023-04-10 |
Shane Harold schnittjer |
allseasongutter@outlook.com |
Webster city |
Hamilton |
Iowa |
Andrea Rae schnittjer |
Shane Ethan schnittjer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shane Harold schnittjer |
allseasongutter@outlook.com |
Self |
Webster City |
Hamilton |
Iowa |
Andrea Rae schnittjer |
Shane Ethan schnittjer |
Signed |
108 |
2020-04-01 16:50 |
Anonymous (not verified) |
206.72.23.71 |
Heartland Renovations, LLC |
Limited Liability Company |
50253 290th Street, Kelley, IA 50134 |
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. |
2020-04-01 |
Troy Van Maaren |
almostanything2@gmail.com |
Kelley |
Iowa |
United States |
Tammy J Reid |
Todd L Greenslit |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Troy Van Maaren |
almostanything2@gmail.com |
Member |
Kelley |
Story |
Iowa |
Tammy J Reid |
Todd L Greenslit |
Signed |
1068 |
2022-04-25 06:07 |
Anonymous (not verified) |
172.58.84.213 |
Alondra Canedo Orta |
Limited Liability Company |
4100 Hubbell Ave Apt#80 Des Moines IA 50317 |
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. |
2022-04-25 |
Alondra Canedo Orta |
alondracanedo34@gmail.com |
Des Moines |
Polk county |
Iowa |
Marvin Bonilla |
Alondra Canedo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alondra Canedo Orta |
alondracanedo34@gmail.com |
Subcontractor Installer |
Des Moines |
Polk county |
Iowa |
Marvin Bonilla |
Alondra Canedo |
Signed |