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Nonelection of Workers' Compensation or Employers' Liability Coverage

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Showing 31 - 40 of 2196.   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:
2169 2024-04-22 09:49 Anonymous (not verified) 94.188.205.166 Galatic Service LLC Proprietorship 623 1st street silvis IL 61282 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. 2024-04-22 Marcos Gonzales Marcosg300@yahoo.com Silvis Rock Island IL Jordan lyod Jordan Nisiewicz Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas city Johnson MO Marcos Gonzales Jordan Lyod Signed
2168 2024-04-22 08:18 Anonymous (not verified) 94.188.207.228 Mattson's Floor Covering Proprietorship 2073 Sandy Lane 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. 2024-04-22 Blaine Linn Mattson tmatzan99@yahoo.com Oquawka Henderson Illinois Cheryl Ross Larry Rheinschmidt Signed (1) The employer does not elect the employers’ liability coverage. Blaine Mattson tmatzan22@yahoo.com owner Oquawka Henderson Illinois Cheryl Ross Larry Rheinschmidt Signed
2167 2024-04-21 22:01 Anonymous (not verified) 94.188.205.177 The Duerson Corportaion Proprietorship 601 1st Ave N, Altoona, IA 50009 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. 2024-04-21 Nicholas John Myers myersnicholasj@gmail.com Norwalk IA United States Theresa Myers Bradyn Smith Signed (1) The employer does not elect the employers’ liability coverage. Nicholas John Myers myersnicholasj@gmail.com Owner Norwalk IA United States Theresa Myers Bradyn Smith Signed
2166 2024-04-20 13:38 Anonymous (not verified) 94.188.205.175 Cedar Valley Seamless, LLC Limited Liability Company 1184 215th St, Jesup, IA 50648 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. 2024-04-20 Andrew Richard Trumbauer cedarvalleyseamlessllc@gmail.com Jesup Buchanan Iowa James William Masteller Andrew William Hamilton Signed (1) The employer does not elect the employers’ liability coverage. Andrew Richard Trumbauer cedarvalleyseamlessllc@gmail.com Owner/Operator Jesup Buchanan Iowa James William Masteller Andrew William Hamilton Signed
2165 2024-04-19 14:05 Anonymous (not verified) 94.188.207.225 Apex Striping LLC Limited Liability Company 1325 Western Ave, 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. 2024-04-19 Chaz Ernest Torres admin@apexstripingia.com Cedar Falls Blackhawk Iowa Theresa Jo Torres Eloy James Torres Signed (1) The employer does not elect the employers’ liability coverage. Chaz Ernest Torres admin@apexstripingia.com Self Cedar Falls Blackhawk Iowa Theresa Jo Torres Eloy James Torres Signed
2164 2024-04-19 13:52 Anonymous (not verified) 94.188.205.167 RKB Designs LLC Limited Liability Company 4333 Cedar St, Davenport, IA 52806 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. 2024-04-19 Ashley Rocca roccafive@gmail.com Davenport IA United States Nicholas Rocca Joni Long Signed (1) The employer does not elect the employers’ liability coverage. Ashley Rocca roccafive@gmail.com Self Davenport IA United States Nicholas Rocca Joni Long Signed
2163 2024-04-19 08:53 Anonymous (not verified) 94.188.205.174 George Petree Proprietorship 1219 N 7th St. Burlington, IA 52601 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. 2024-04-19 George Harlan Petree g_petree@hotmail.com Burlington Des Moines Iowa Cheryl Ross Larry Rheinschmidt Signed (1) The employer does not elect the employers’ liability coverage. George Harlan Petree g_petree@hotmail.com owner Burlington Des Moines Iowa Cheryl Ross Larry Rheinschmidt Signed
2162 2024-04-18 19:25 Anonymous (not verified) 94.188.205.177 Escobar Enterprises, LLC Limited Liability Company 125 East Broad Street, Des Moines, Iowa 50315 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. 2024-04-18 Jesse Escobar jesse@escobar-enterprises.com Des Moines Polk Iowa Rene Mauricio Martinez Jessa Caitlin Marfal Signed (1) The employer does not elect the employers’ liability coverage. Jesse Escobar jesse@escobar-enterprises.com owner Des Moines Polk Iowa Rene Mauricio Martinez Jessa Caitlin Marfal Signed
2161 2024-04-18 15:40 Anonymous (not verified) 94.188.205.176 Thad A Holdefer Proprietorship 313 Ruthella Drive West Burlington, IA 52655 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. 2024-04-18 Thad A. Holdefer thadholdefer@yahoo.com West Burlington Des Moines Iowa Cheryl Ross Larry Rheinschmidt Signed (1) The employer does not elect the employers’ liability coverage. Thad A Holdefer thadholdefer@yahoo.com owner West Burlington Des Moines Iowa Cheryl Ross Larry Rheinschmidt Signed
2160 2024-04-17 18:21 Anonymous (not verified) 94.188.207.226 QC Remodeling LLC Limited Liability Company 421 West Broadway, Ste 302 Council Bluffs, IA 51503 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. 2024-04-17 Fernando Ibarra ibarra_fernando@hotmail.com Rock Island Rock Island Illinois Paula Barria Louis Valencia Signed (1) The employer does not elect the employers’ liability coverage. Fernando Ibarra ibarra_fernando@hotmail.com Owner Rock Island Rock Island Illinois Paula Barria Louis Valencia Signed