Official State of Iowa Website Here is how you know
Agencies A-Z Programs & Services
  1. Nonelection of Workers' Compensation or Employers' Liability Coverage
  2. Table

Nonelection of Workers' Compensation or Employers' Liability Coverage

Primary tabs

Secondary tabs

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:
885 2022-02-02 14:13 Anonymous (not verified) 104.201.67.178 Maria DeLeon Proprietorship 2805 10th Avenue North, Fort Dodge, IA 50501 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. 2022-01-01 Maria DeLeon scottthomascpa@msn.com Fort Dodge Webster Iowa Rich Darr Mari Lopez Signed (1) The employer does not elect the employers’ liability coverage. Scott D Thomas s.thomas@nationwideofficecare.com Consultant West Des Moines IA United States Rich Darr Mari Lopez Signed
1107 2022-05-16 15:28 Anonymous (not verified) 64.33.230.163 hangar 8 spray service Limited Liability Company 1626 airport dr 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. 2022-05-16 jed douglas hansen hangar.8@hotmail.com Clark South Dakota United States jed douglas hansen jed douglas hansen Signed (1) The employer does not elect the employers’ liability coverage. jed douglas hansen hangar.8@hotmail.com contract Clark South Dakota United States Jed Hansen Jed Hansen Signed
793 2021-12-14 14:16 Anonymous (not verified) 174.22.96.99 Dubuque County Energy District Limited Liability Company 700 Locust Street, #195 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. 2021-12-10 Michaela Marie Freiburger michaela@energydistrict.org Dubuque Dubuque IA Diane Freiburger, Mother Michael Freiburger, Father Signed (1) The employer does not elect the employers’ liability coverage. Michaela Marie Freiburger michaela@energydistrict.org Contracted Vendor for the Dubuque County Energy District Dubuque Dubuque IA Diane Freiburger Michael Freiburger Signed
240 2020-08-23 15:03 Anonymous (not verified) 67.45.96.12 Wellik & Sons, LLC Limited Liability Company 1770 HWY 18, Garner, IA 50438 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. 2020-08-23 Robert Alan Roths robrothsrams@yahoo.com Garner Hancock Iowa Ashley S Wellik Joshua P. Wellik Signed (1) The employer does not elect the employers’ liability coverage. Joshua Paul Wellik wellikandsons@gmail.com contractor Garner Hancock Iowa Ashley S Wellik Joshua P Wellik Signed
1154 2022-06-14 00:27 Anonymous (not verified) 174.213.144.227 Arben Bahtirovic Partnership 3060 South East Grimes Blvd, Suite 100-300 Grimes, Iowa 50111 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. 2022-06-14 Arben Bahtirovic arben2002@gmail.com West Des Moines Polk IOWA Senida bahtirovic Mario mandic Signed (1) The employer does not elect the employers’ liability coverage. Arben Bahtirovic arben2002@gmail.com Contractor West Des Moines Polk IOWA Senida bahtirovic Marijo mandic Signed
1200 2022-07-11 19:24 Anonymous (not verified) 208.126.69.118 CMG Safety Limited Liability Company 325 1st 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. 2022-07-11 Chace Michael Garner chgarner18@gmail.com Truro Madison Iowa Josh Tomkins Kirsten Schirm Signed (1) The employer does not elect the employers’ liability coverage. Josh Tompkins josh.thomkins@307safety.com Contractor Gillette Cambell Wyoming Chace Garner Kirsten Schirm Signed
1434 2023-01-31 07:12 Anonymous (not verified) 162.233.75.173 abc Proprietorship 1122 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. 2023-01-31 Brian Yurko byurko714@gmail.com Cedar Falls Black Hawk Iowa pete re pete Signed (1) The employer does not elect the employers’ liability coverage. LHE byurko@leafhome.com contractor Deerfield Beach Florida United States pete re pete Signed
2038 2024-02-08 07:44 Anonymous (not verified) 94.188.205.167 Travis Toney Limited Liability Company 932 w12th street south newton ia 50208 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. 2024-02-08 Travis Duane Toney travistoney1984@gmail.com Newton United States IA Rick lee Toney Brenda Ann Toney Signed (1) The employer does not elect the employers’ liability coverage. Phil glazer kg_Info@capitallandscaping.com Contractor Des Moines United States IA Rick lee Toney Brenda Ann Toney Signed
2072 2024-03-01 11:27 Anonymous (not verified) 94.188.207.226 SoldFast Real Estate L.L.C. Limited Liability Company 5525 Meredith Drive Des Moines, Iowa 50310 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. 2024-03-02 Darlyn Fructuoso thejjscleaningllc@gmail.com Des Moines Polk IA Beatriz Musselman Darlyn Fructuoso Signed (1) The employer does not elect the employers’ liability coverage. Cody Wilkinson cody@soldfast.com Contractor Des Moine Polk IA Beatriz Musselman Darlyn Fructuoso Signed
2225 2024-05-15 20:43 Anonymous (not verified) 94.188.205.168 Vibrant Supported Community Living WHC Limited Liability Company 1036 66th 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. 2024-05-15 Shinaye Finney-EL Finneyel1973@icloud.com WINDSOR HEIGHTS Iowa United States Shinaye Finney-EL Shinaye Finney-EL Signed (1) The employer does not elect the employers’ liability coverage. Shinaye Finney-EL Finneyel1973@icloud.com Contractor WINDSOR HEIGHTS Iowa United States Shinaye Finney-EL Shinaye Finney-EL Signed