1458 |
2023-02-16 07:20 |
Anonymous (not verified) |
94.188.205.167 |
Windsor Earth Works, dba Wells Commercial Flooring |
Limited Liability Company |
1442 73rd Street, Windsor Heights, Ia. 50324 |
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. |
2023-02-16 |
Timothy E Wells |
wellsba1@msn.com |
Windsor Heights |
Polk |
Iowa |
Leonard Klug |
Barbara Wells |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Barbara Wells |
wellsba65@gmail.com |
Spouse |
Windsor Heights |
Polk |
Iowa |
Leonard Klug |
Timothy Wells |
Signed |
1327 |
2022-10-06 12:23 |
Anonymous (not verified) |
71.39.227.238 |
RICK OBEREMBT |
Proprietorship |
1702 SYCAMORE ST, DALLAS CNETER, IA 50063 |
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. |
2022-10-05 |
RICK OBEREMBT |
werock83@gmail.com |
DALLAS CENTER |
DALLAS |
IOWA |
ABBEY LUELLEN |
DON RICHARDSON |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RICK OBEREMBT |
werock83@gmail.com |
SELF |
DALLAS CENTER |
DALLAS |
IOWA |
ABBEY LUELLEN |
DON RICHARDSON |
Signed |
446 |
2021-03-23 12:39 |
Anonymous (not verified) |
174.198.72.209 |
Final Finish llc |
Limited Liability Company |
3824 12th 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. |
2021-03-23 |
Wesley Robert Detman |
wesdet@gmail.com |
Drs Moines |
Polk |
Iowa |
Leah Laxton |
Lucas Laxton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wesley Robert Detman |
wesdet@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Leah Laxton |
Lucas Laxton |
Signed |
2112 |
2024-03-22 08:22 |
Anonymous (not verified) |
94.188.205.174 |
WR TREE SERVICES |
Limited Liability Company |
1176 highway 9 Lansing 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. |
2024-03-22 |
Wesley Adam Remund |
wesleyadamremund@gmail.com |
Lansing |
Allamakee |
Iowa |
JENNIFER K Harris |
Stefan M Remund |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wesley Adam Remund |
wesleyadamremund@gmail.com |
OWNER |
Lansing |
Allamakee |
Iowa |
Jennifer K Harris |
Stefan M Remund |
Signed |
1715 |
2023-06-28 09:48 |
Anonymous (not verified) |
94.188.207.229 |
Charles westbrook |
Limited Liability Company |
2374 31st a Moline |
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. |
2023-06-28 |
Charles Micheal westbrook |
Westbrook.69.mw@gmail.com |
Moline |
USA |
Illinois |
Taylor Davis |
N/a |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Charles Micheal Westbrook |
Westbrook.69.mw@gmail.com |
Gf |
Moline |
IL |
United States |
Taylor davis |
N/a |
Signed |
486 |
2021-04-19 15:09 |
Anonymous (not verified) |
65.103.82.36 |
Westeros Property Maintenance, LLC |
Limited Liability Company |
2004 Leclaire 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. |
2020-10-01 |
Theodore Brown |
westerospropertymaintenance@outlook.com |
Davenport |
Scott |
IA |
Jordan |
Kayla |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Theodore Brown |
westerospropertymaintenance@outlook.com |
Owner |
Davenport |
Scott |
IA |
Jordan |
Kayla |
Signed |
1748 |
2023-07-17 06:35 |
Anonymous (not verified) |
94.188.205.177 |
Westys paint and stain llc |
Limited Liability Company |
1961 150th st waverly, ia 50677 |
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. |
2023-07-17 |
Kaitlin westendorf |
westyspaint@gmail.com |
Waverly |
Bremer |
Iowa |
Kathy westendorf |
Michael westendorf |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Westys paint & stain llc |
westyspaint@gmail.com |
Owner |
Waverly |
Bremer |
Iowa |
Kathy westendorf |
Michael westendorf |
Signed |
1507 |
2023-03-09 08:16 |
Anonymous (not verified) |
94.188.207.230 |
Greufe Construction |
Proprietorship |
2820 230th 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. |
2023-01-01 |
Wayne Greufe |
wgreufe@wmtel.net |
Blairsburg |
US |
United States |
Janet Greufe |
Janet Greufe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wayne Greufe |
wgreufe@wmtel.net |
Friend |
Blairsburg |
US |
United States |
Janet Greufe |
Janet Greufe |
Signed |
532 |
2021-05-27 11:28 |
Anonymous (not verified) |
50.82.70.103 |
WHAT BBQ & BAR, LLC |
Limited Liability Company |
106 S CODY RD 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. |
2021-05-27 |
SHILL HUNTER |
WHATBBQBAR@GMAIL.COM |
LECLAIRE |
SCOTT |
IOWA |
WHITNEY LANE |
ROBERT CAIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SHILL HUNTER |
WHATBBQBAR@GMAIL.COM |
OWNER |
LECLAIRE |
SCOTT |
IOWA |
WHITNEY LANE |
ROBERT CAIN |
Signed |
1929 |
2023-11-30 10:46 |
Anonymous (not verified) |
94.188.207.225 |
White Masonry, Inc. |
Proprietorship |
15141 Bluff Trl., Carlisle, IA 50047 |
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. |
2023-11-30 |
Jeff White |
whitemasonry1979@hotmail.com |
Carlisle |
IA |
IA |
Cathleen Marie White |
Sam Jeffrey White |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeffrey Dean White |
WHITEMASONRY1979@HOTMAIL.COM |
Self |
CARLISLE |
ia |
ia |
Cathleen Marie White |
Sam Jeffrey White |
Signed |