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Nonelection of Workers' Compensation or Employers' Liability Coverage

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Showing 2181 - 2190 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:
1516 2023-03-14 09:00 Anonymous (not verified) 94.188.207.225 Bart Fuller & James Fuller DBA Fuller & Sons Partnership 1302 Lincoln ST., Ruthven, IA 51358 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. 2023-03-14 Bart Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. Bart Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed
2107 2024-03-19 12:33 Anonymous (not verified) 94.188.205.175 Elit Construction and Masonry LLC Partnership 3309 Wright St. Des Moines, Ia 50316 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. 2023-03-19 Manuel Mejia elitconstructionmasonryllc@gmail.com Des Moines Polk Iowa Heather Garber Kyle Johnson Signed (1) The employer does not elect the employers’ liability coverage. Manuel Mejia elitconstructionmasonryllc@gmail.com self Des Moines Polk Iowa Heather Garber Kyle Johnson Signed
557 2021-07-07 09:51 Anonymous (not verified) 66.188.136.150 Andrew Thompson-Sutherland Proprietorship 3200 Daniel Lane Apt. 207 Monroeville, PA 15146 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. 2021-07-06 Andrew Thompson-Sutherland kschumacher@tricorinsurance.com Monroeville Allegheny PA Mitch Kemp Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Andrew Thompson-Sutherland kschumacher@tricorinsurance.com Same Monroeville Allegheny PA Mitch Kemp Shuree Behr Signed
1628 2023-05-09 08:00 Anonymous (not verified) 94.188.205.175 Servin Drywall Proprietorship 6311 Underwood Ave SW, Cedar Rapids, IA 52404 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. 2023-05-09 Arcel Servin arcelservin77@gmail.com Cedar Rapids Linn Iowa Rolandas Bitanas Kirk Strunk Signed (1) The employer does not elect the employers’ liability coverage. Arcel Servin arcelservin77@gmail.com Self Cedar Rapids Linn Iowa Rolandas Bitanas Kirk Strunk Signed
2219 2024-05-10 10:20 Anonymous (not verified) 94.188.207.228 Froyo To Go, LLC Limited Liability Company 909 4th Ave. South, Denison, 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. 2024-05-10 Derek Lambert drdereklambert@gmail.com Denison Crawford Iowa Maria Sandoval Nahomy Fernandez Alvarado Signed (1) The employer does not elect the employers’ liability coverage. Trevis Beeck trevis.beeck.u0ms@statefarm.com I am the State Farm Agent who is submitting the Business Policy Denison Crawford Iowa Maria Sandoval Nahomy Fernandez Alvarado Signed
669 2021-10-13 08:24 Anonymous (not verified) 64.191.11.62 E360 Building Company, Inc. Proprietorship PO Box 363, Cedar Falls, IA 50613 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. 2021-10-13 Mark Miller mark@e360buildingco.com Cedar Falls Black Hawk Iowa Laetyn Miller Grant Williamson Signed (1) The employer does not elect the employers’ liability coverage. Mark Miller markm@cfu.net Self Cedar Falls Black Hawk Iowa Laetyn Miller Grant Williamson Signed
1740 2023-07-11 12:22 Anonymous (not verified) 94.188.205.168 Innovators Construction LLC Limited Liability Company 3234 180th St., Homestead, IA 52236 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. 2023-07-11 Guadalupe Ramirez imfo@jmdrywallonline.com Homestead Iowa Iowa Itali Ramírez Juan m Ramírez Signed (1) The employer does not elect the employers’ liability coverage. Juan M Ramírez info@jmdrywallonline.com Business partner Homestead Iowa Iowa Itali Ramírez Juan m Ramírez Signed
781 2021-12-08 08:41 Anonymous (not verified) 172.58.87.49 Diggins Installations Proprietorship 1619 48th st Des moines ia 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. 2021-12-06 Danny Allan Diggins ddigdan@gmail.com Des Moines Polk 1619 48th st Nancy Davis Angie Pilcher Signed (1) The employer does not elect the employers’ liability coverage. Danny Diggins ddigdan@gmail.com Self Des moines Polk Ia Nancy Davis Angie pilcher Signed
972 2022-03-14 18:01 Anonymous (not verified) 207.32.37.48 Lynx Ag LLC Limited Liability Company 510 H Ave, Churdan, IA 50050 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. 2022-03-14 Abby Glendenning lanceandabby@wccta.net Churdan Greene Iowa Kim Kersey Shelly Brus Signed (1) The employer does not elect the employers’ liability coverage. Lance Glendenning lanceandabby@wccta.net President Churdan Greene Iowa Kim Kersey Shelly Brus Signed
13 2019-12-30 14:27 Anonymous (not verified) 173.24.181.211 TERRY GALBRAITH DBA HUNEYDEW CONSTRUCTION Proprietorship 706 SUNSHINE RUN ARNOLDS PARK IA 51331 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. 2019-11-27 TERRY GALBRAITH CT_INSPECTIONS@MEDIACOMBB.NET ARNOLDS PARK DICKINSON IA KRIS WALKER JOE LORING Signed (1) The employer does not elect the employers’ liability coverage. TERRY GALBRAITH CT_INSPECTIONS@MEDIACOMBB.NET SELF ARNOLDS PARK DICKINSON IA JOE LORING KRIS WALKER Signed