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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:
639 2021-09-13 16:10 Anonymous (not verified) 50.81.97.207 Copic Home Maintenance LLC dba Des Moines Drywall Repair Limited Liability Company 1548 24th 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. 2021-09-13 Clint R Copic crcopic@gmail.com Des Moines Polk Iowa Veronica G. Torres Dan Waidelich Signed (1) The employer does not elect the employers’ liability coverage. Clint R Copic dmdrywallrepair@gmail.com self Des Moines Polk Iowa Veronica G Torres Dan Waidelich Signed
1112 2022-05-17 14:15 Anonymous (not verified) 24.162.40.106 Davis AG Service Texas LLC Limited Liability Company P.O. Box 1475 Fabens, Texas 79838 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. 2022-05-17 John Anthony Davis turbinespacemonkey@yahoo.com Mountain View Stone Arkansas Vicki Lynne Ivey Maggielyn Marie Paul Signed (1) The employer does not elect the employers’ liability coverage. John Anthony Davis turbinespacemonkey@yahoo.com Owner Mountain View Stone Arkansas Vicki Lynne Ivey Maggielyn Marie Paul Signed
1113 2022-05-17 14:20 Anonymous (not verified) 24.162.40.106 John Anthony Davis Proprietorship P.O. Box 2551 Mountain View, AR 72560 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. 2022-05-17 John Anthony Davis turbinespacemonkey@yahoo.com Mountain View Stone Arkansas Vicki Lynne Ivey Maggielyn Marie Paul Signed (1) The employer does not elect the employers’ liability coverage. John Anthony Davis turbinespacemonkey@yahoo.com Proprietor Mountain View Stone Arkansas Vicki Lynne Ivey Maggielyn Marie Paul Signed
1615 2023-04-27 17:42 Anonymous (not verified) 94.188.207.227 John Anthony Davis Proprietorship P.O. Box 2551 Mountain View, AR 72560 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. 2023-04-27 John Anthony Davis turbinespacemonkey@yahoo.com Mountain View Stone Arkansas Vicki Lynne Ivey Maggielyn Marie Paul Signed (1) The employer does not elect the employers’ liability coverage. John Anthony Davis turbinespacemonkey@yahoo.com Proprietor Mountain View Stone Arkansas Vicki Lynne Ivey Maggielyn Marie Paul Signed
1616 2023-04-27 17:46 Anonymous (not verified) 94.188.207.230 Davis AG Service Texas LLC Limited Liability Company P.O. Box 1475 Fabens, Texas 79838 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. 2023-04-27 John Anthony Davis turbinespacemonkey@yahoo.com Mountain View Stone Arkansas Vicki Lynne Ivey Maggielyn Marie Paul Signed (1) The employer does not elect the employers’ liability coverage. John Anthony Davis turbinespacemonkey@yahoo.com Owner Mountain View Stone Arkansas Vicki Lynne Ivey Maggielyn Marie Paul Signed
1565 2023-04-11 09:49 Anonymous (not verified) 94.188.205.177 Leonard Moss Roofing Proprietorship 2018 Superior Street, Webster City, Iowa 50595 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. 2023-04-11 Leonard Moss leonard.moss48@gmail.com Webster City Hamilton Iowa Vicky Hahne Morgan Jensen Signed (1) The employer does not elect the employers’ liability coverage. Leonard Moss leonard.moss48@gmail.com Same Webster City Hamilton Iowa Vicky Hahne Morgan Jensen Signed
2117 2024-03-27 10:38 Anonymous (not verified) 94.188.207.226 ALCON CONSTRUCTION LLC Limited Liability Company 2613 GINDY DR, BELLEVUE, NE 68147 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. 2024-03-27 VALERIE OLONO ALCONCONSTRUCTION2021@GMAIL.COM BELLEVUE SARPY NEBRASKA VICTOR H OLONO GANDARILLA ALEXANDRA GUTIERREZ Signed (1) The employer does not elect the employers’ liability coverage. VALERIE OLONO ALCONCONSTRUCTION2021@GMAIL.COM SELF BELLEVUE SARPY NEBRASKA VICTOR H OLONO GANDARILLA ALEXANDRA GUTIERREZ Signed
2195 2024-04-30 15:31 Anonymous (not verified) 94.188.205.166 Jason Cooper Proprietorship 1181 Western Ave Stockton Iowa 52769 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. 2024-04-30 Jason cooper jvcpainting88@gmail.com Stockton IA United States Violet minssen Hope Bishop Signed (1) The employer does not elect the employers’ liability coverage. Jason cooper jvcpainting88@gmail.com Self Stockton IA United States Violet minssen Hope Bishop Signed
683 2021-10-20 09:39 Anonymous (not verified) 173.23.253.122 Superior Floors Limited Liability Company 704 41st 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. 2021-10-20 Ron Shannon ronshannon3831@gmail.com West Des Moines IA United States Virginia Shannon Virginia Shannon Signed (1) The employer does not elect the employers’ liability coverage. Ron Shannon ronshannon3831@gmail.com Self West Des Moines IA United States Virginia Shannon Virginia Shannon Signed
1213 2022-07-19 14:00 Anonymous (not verified) 198.14.220.143 VLG Build & Remodle LLC Limited Liability Partnership 45547 State HWY 14 Chariton, IA 50049 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. 2022-07-19 Vladimir Golosinskiy VLGCONSTRUCTION@YAHOO.COM Chariton IA United States Vladimir Golosinskiy Vladimir Golosinskiy Signed (1) The employer does not elect the employers’ liability coverage. LILIA GOLOSINSKIY VLGCONSTRUCTION@YAHOO.COM Wife CHARITON Iowa United States LILIA GOLOSINSKIY LILIA GOLOSINSKIY Signed