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Nonelection of Workers' Compensation or Employers' Liability Coverage

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Showing 301 - 310 of 2222.   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:
1551 2023-03-31 13:37 Anonymous (not verified) 94.188.205.176 Nadarevic Group LLC Limited Liability Company 3633 NW 177th Ct, Clive, IA 50325 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. 2023-03-31 Nicole Nadarevic niki@silverstonedevgroup.com Clive Dallas Iowa Jeremy Boysen Brooke Boysen Signed (1) The employer does not elect the employers’ liability coverage. Ajdin Nadarevic ajdin@silverstonedevgroup.com Owner Clive Dallas Iowa Jeremy Boysen Brooke Boysen Signed
684 2021-10-20 13:25 Anonymous (not verified) 65.144.174.26 A and H Home Improvement Limited Liability Company 600 NE 64th 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 Ivan A. Abel aandhhomeimprovement@gmail.com Des Moines Polk Iowa Ken Krogman Bruce Baumgarn Signed (1) The employer does not elect the employers’ liability coverage. Ivan A. Abel aandhhomeimprovement@gmail.com Self Des Moines Polk Iowa Ken Krogman Bruce Baumgarn Signed
248 2020-08-27 16:01 Anonymous (not verified) 142.202.101.194 Nathan Unruh Construction Proprietorship P.O. Box 181 Mechanicsville, IA. 52306 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. 2020-08-27 Nathan Unruh Nathanunruh@gmail.com Mechanicsville Cedar Iowa Randy Rouse Bruce Seehusen Signed (1) The employer does not elect the employers’ liability coverage. Nathan Unruh nathanunruh@gmail.com Same person Mechanicsville Cedar Iowa Randy Rouse Bruce Seehusen Signed
2215 2024-05-08 22:07 Anonymous (not verified) 94.188.207.223 Self Employed-Ryan Thornton Proprietorship 8403 Horton Ave Urbandale IA 50322 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. 2024-05-08 Ryan M Thornton rt6366155@gmail.com Urbandale Polk Iowa April Oxendale Bruce Thornton Signed (1) The employer does not elect the employers’ liability coverage. Ryan Thornton rt6366155@gmail.com Self Urbandale Polk Iowa April Oxendale Bruce Thornton Signed
2074 2024-03-04 16:56 Anonymous (not verified) 94.188.207.224 IG painting Llc Limited Liability Company 416 51st ST West des moines,IA 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. 2024-03-01 antonio J Iglesias antonio_joserene@hotmail.com west Des moines polk iowa Raul Gomez Bruno Cruz Signed (1) The employer does not elect the employers’ liability coverage. Antonio J Iglesias antonio_joserene@hotmail.com not relationship West des Moines polk iowa Raul Gomez Bruno cruz Signed
1329 2022-10-10 10:55 Anonymous (not verified) 173.25.222.69 Eli's Limited Liability Company 931 S Van Buren St Iowa City, Iowa 52240 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. 2022-10-10 Elijah Ortiz eortiz15@gmail.com Iowa City Johnson Iowa Erica Mason Bryan Horrell Signed (1) The employer does not elect the employers’ liability coverage. Elijah Ortiz eortiz15@gmail.com Proprietor Iowa City Johnson Iowa Erica Mason Bryan Horrell Signed
1373 2022-11-16 12:28 Anonymous (not verified) 173.22.187.22 MCDONALD'S LAWN & TREE SERVICES Proprietorship 1130 N. 4 AVE. W. NEWTON IA 50208 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. 2022-11-16 Roger McDonald RABBITMCDONALD@HOTMAIL.COM Newton IA United States Patricia McMahon Bryan McMahon Signed (1) The employer does not elect the employers’ liability coverage. Roger McDonald RABBITMCDONALD@HOTMAIL.COM Self Newton IA United States Patricia McMahon Bryan McMahon Signed
2044 2024-02-15 09:52 Anonymous (not verified) 94.188.205.168 Messenger Trucking LLC Limited Liability Company 1869 255th St., Fairfield, IA 52556 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. 2024-02-08 Timothy Duncan Messenger tmessengertrucking@gmail.com Fairfield Jefferson Iowa Casey Messenger Bud Smith Signed (1) The employer does not elect the employers’ liability coverage. Timothy Duncan Messenger tmessengertrucking@gmail.com Self Fairfield Jefferson Iowa Casey Messenger Bud Smith Signed
2005 2024-01-29 08:50 Anonymous (not verified) 94.188.207.226 Laser Line Striping Proprietorship 10572 320th 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. 2024-01-29 Dean Weikert d.lineuponline@yahoo.com Ackley Iowa United States Linda Weikert Ca Signed (1) The employer does not elect the employers’ liability coverage. Kain Helmke d.lineuponline@yahoo.com D.lineuponline@yahoo.com Ackley Butler Iowa Linda Weikert Kain Helmke Signed
882 2022-02-02 11:09 Anonymous (not verified) 67.55.205.135 Tree & Forestry Equipment Partnership 201 Deer Haven St., Polk City, IA 50226 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. 2022-02-02 Jennifer Hicks jennifer@treeandforestry.com Gowrie Webster Iowa Chad Hicks Caden Konecne Signed (1) The employer does not elect the employers’ liability coverage. Jennifer Hicks jennifer@treeandforestry.com self Gowrie Webster Iowa Chad Hicks Caden Konecne Signed