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Nonelection of Workers' Compensation or Employers' Liability Coverage

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Showing 301 - 310 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:
1304 2022-09-11 22:05 Anonymous (not verified) 174.198.65.241 Bruce g Sellner Proprietorship 40998 597th ave new ulm mn 56073 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. 2022-09-11 Bruce g Sellner bgsellner74@gmail.com New ulm Nicollet Minnesota Carol m aura Steve l griebel Signed (1) The employer does not elect the employers’ liability coverage. Bruce g Sellner bgsellner74@gmail.com Owner New ulm Nicollet Mn Carol m aura Steve l griebel Signed
1869 2023-10-17 00:59 Anonymous (not verified) 94.188.207.230 Lisa's Janitorial Limited Liability Company 406 S. 10th Street Sac City, Iowa 50583 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. 2023-10-16 Bruce Homer bhjhomer69@gmail.com Sac City Sac Iowa Autumn Simonsen Misty Brewster Signed (1) The employer does not elect the employers’ liability coverage. Bruce Homer bhjhomer69@gmail.com Self Sac City Sac Iowa Autumn Simonsen Misty Brewster Signed
1035 2022-04-05 12:03 Anonymous (not verified) 199.120.121.97 Bruce Peters Painting Proprietorship 53568 Rosewood Road, Walnut IA 51577 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. 2022-04-05 Bruce Peters bpeters1992@yahoo.com Walnut Pottawattamie Iowa Marie Peters Angie Gettys Signed (1) The employer does not elect the employers’ liability coverage. Bruce Peters bpeters1992@yahoo.com self Walnut Pottawattamie Iowa Marie Peters Angie Gettys Signed
1149 2022-06-09 17:43 Anonymous (not verified) 174.235.192.238 Bryan Linares Limited Liability Company 630 Hawthorne Ave 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. 2022-06-09 Bryan Linares bryan.linares7798@gmail.com Crete Saline Nebraska Bryan Linares Chris Linares Signed (1) The employer does not elect the employers’ liability coverage. Christopher Linares chris5linares1995@gmail.com Brother Crete Saline Nebraska Bryan Linares Chris Linares Signed
1034 2022-04-05 11:43 Anonymous (not verified) 75.162.133.214 Riftworks Wood Manufactory Proprietorship 3807 Adams Ave, Des moines, Iowa 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. 2022-04-05 Bryan Siever bryan@siever.us Des Moines IA United States Cakeb Payne Tyler Anderson Signed (1) The employer does not elect the employers’ liability coverage. Bryan siever bryan@siever.us Business owner Des Moines IA United States Caleb Payne Tyler Anderson Signed
1662 2023-05-25 12:52 Anonymous (not verified) 94.188.205.176 Affordable Painting and Renovations of Iowa LLC Limited Liability Company 1418 NW Applewood St. Ankeny, IA 50023 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. 2023-05-25 Bryan Thieleke affordablerenoiowa@yahoo.com Ankeny Polk Iowa Mike Kaut Adam Lozano Signed (1) The employer does not elect the employers’ liability coverage. Bryan Thieleke affordablerenoiowa@yahoo.com Owner Ankeny Polk Iowa Mike kaut Adam lozano Signed
1663 2023-05-25 12:56 Anonymous (not verified) 94.188.205.167 Affordable Painting and Renovations of Iowa LLC Limited Liability Company 1417 NW Applewood St. Ankeny, IA 50023 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. 2023-05-25 Bryan Thieleke affordablerenoiowa@yahoo.com Ankeny Polk Iowa Mike kaut Adam lozano Signed (1) The employer does not elect the employers’ liability coverage. Bryan Thieleke affordablerenoiowa@yahoo.com Owner Ankeny Polk Iowa Mike kaut Adam lozano Signed
2034 2024-02-07 11:58 Anonymous (not verified) 94.188.207.230 Bryce Abbott Proprietorship 114 West Linn Street, Lone Tree, IA 52755 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. 2024-01-31 Bryce David Abbott bryceabbott86@gmail.com Lone Tree Johnson United States Dixie Abbott Andy Abbott Signed (1) The employer does not elect the employers’ liability coverage. Bryce Abbott bryceabbott86@gmail.com Self Lonetree Johnson IA Dixie Abbott Andy Abbott Signed
1410 2023-01-06 10:58 Anonymous (not verified) 173.25.103.95 Bryce Kenworthy Proprietorship 155 NW Maple St Elkhart IA 50073 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. 2023-01-06 Bryce Kenworthy midwest.fencingandconstruction@gmail.com Elkhart Polk Iowa Kevin Corn Nicole Almburg Signed (1) The employer does not elect the employers’ liability coverage. Bryce Kenworthy midwest.fencingandconstruction@gmail.com Owner Elkhart Polk Iowa Kevin Corn Nicole Almburg Signed
2134 2024-04-04 08:10 Anonymous (not verified) 94.188.205.169 TERRA CONSTRUCTION LLC Limited Liability Company 621 Oak Park Ave Des Moines, IA 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. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2024-04-04 Bryce Shabazz block.radio@yahoo.com Des Moines Polk Iowa Megan Donigan George Hana Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jessica L Heller Jessica.heller@adp.com Insurance Agent Allentown Lehigh PA Megan Donigan George Hana Signed