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Nonelection of Workers' Compensation or Employers' Liability Coverage

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# 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:
600 2021-08-12 11:04 Anonymous (not verified) 173.19.179.111 ELIJAH HIX Proprietorship PO BOX 465 MILFORD IA 51351 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. 2021-08-11 ELIJAH HIX HIXSKIDOO800@GMAIL.COM MILFORD DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. ELIJAH HIX HIXSKIDOO800@GMAIL.COM SELF MILFORD DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
670 2021-10-13 12:30 Anonymous (not verified) 173.19.179.111 MULLER TRANSPORT LLC Limited Liability Company 2083 260TH ST MILFORD, IA 51351 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 PAUL MULLER MULLERTANSPORTLLC@GMAIL.COM MILFORD DICKINSON IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. PAUL MULLER JOEL@WALKERINSURANCEIA.COM SELF MILFORD DICKINSON IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
966 2022-03-11 10:04 Anonymous (not verified) 173.19.189.168 Steger Siding & Construction Limited Liability Company 1020 25th 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. 2022-03-11 Jared Steger jared.steger@gmail.com Marion IA United States Jared Steger Jared Steger Signed (1) The employer does not elect the employers’ liability coverage. Jared Steger jared.steger@gmail.com self Marion IA United States Jared Steger Jared Steger Signed
334 2020-12-07 12:38 Anonymous (not verified) 173.19.190.160 Broadband Installations of Iowa LLC Limited Liability Company P.O. Box 728 Carroll, IA 51401 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. 2020-12-07 Charles Wood cwood.bband@outlook.com CEDAR RAPIDS IA IA Eva Wood Tamara Wood Signed (1) The employer does not elect the employers’ liability coverage. Skyla Siech skylabbi@outlook.com Offcie Manager Ely Linn Iowa Melvin Harter Eddie Bell Signed
255 2020-09-11 13:42 Anonymous (not verified) 173.190.65.6 A Fisk Trucking, LLC Limited Liability Company PO Box 332, Strawberry Point, IA 52076 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. 2020-08-14 Andrew Fisk afisktrucking@gmail.com Strawberry Point Clayton Iowa Pamela Vaske Crystal Thole Signed (1) The employer does not elect the employers’ liability coverage. A Fisk Trucking, LLC afisktrucking@gmail.com Member/Manager Strawberry Point Clayton Iowa Pamela Vaske Crystal Thole Signed
145 2020-04-30 16:09 Anonymous (not verified) 173.191.206.253 Mark Knapp Proprietorship 11244 Linden Rd 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. 2020-04-30 Mark A Knapp mlmlknapp@iowatelecom.net Linden Iowa United States Phil Hesseltine Kathy Hesseltine Signed (1) The employer does not elect the employers’ liability coverage. Mark Knapp mlmlknapp@iowatelecom.net self Linden Iowa United States Phil Hesseltine Kathy Hesseltine Signed
1424 2023-01-17 17:34 Anonymous (not verified) 173.191.246.189 Jabe Ramsey Proprietorship 216 South Park Street Osceola, IA 50213 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. 2023-01-17 Jabe Hatfield Ramsey jaberamsey@icloud.com Osceola IA United States Sofia Contreras Katie Anne Carson Signed (1) The employer does not elect the employers’ liability coverage. Jabe Ramsey jaberamsey@icloud.com ME Osceola Clarke IOWA Sofia Contreras Katie Anne Carson Signed
1291 2022-09-02 13:24 Anonymous (not verified) 173.20.146.6 Nicci Keck LLC Limited Liability Company 1107 Pheasant Valley St, Iowa City, IA 52246 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. 2020-09-02 Nicole Keck niccikeckllc@gmail.com Iowa City Iowa United States Evangeline Kadera Denise Kandel Signed (1) The employer does not elect the employers’ liability coverage. Nicole Keck niccikeckllc@gmail.com Managing Member/Owner/President Iowa City Johnson Iowa Evangeline Kadera Denise Kandel Signed
1292 2022-09-02 13:26 Anonymous (not verified) 173.20.146.6 Nicci Keck LLC Limited Liability Company 1107 Pheasant Valley St, Iowa City, IA 52246 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. 2020-09-02 Benjamin Darbro darbrob@gmail.com Iowa City Iowa United States Evangeline Kadera Denise Kandel Signed (1) The employer does not elect the employers’ liability coverage. Nicole Keck niccikeckllc@gmail.com Managing Member/Owner/President Iowa City Johnson Iowa Evangeline Kadera Denise Kandel Signed
949 2022-03-04 16:09 Anonymous (not verified) 173.20.147.171 Duwa Waterproofing LLC Limited Liability Company 729 Deer view Ave, Tiffin, IA 52340 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. 2022-03-04 Stacy Duwa duwawaterproofing@gmail.com Tiffin Johnson Iowa Lauren Obermann Don Vittetoe Signed (1) The employer does not elect the employers’ liability coverage. Stacy Duwa duwawaterproofing@gmail.com owner Tiffin Johnson Iowa Lauren Obermann Don Vittetoe Signed