Official State of Iowa Website Here is how you know
Agencies A-Z Programs & Services
  1. Nonelection of Workers' Compensation or Employers' Liability Coverage
  2. Table

Nonelection of Workers' Compensation or Employers' Liability Coverage

Primary tabs

Secondary tabs

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:
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
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
156 2020-05-13 20:37 Anonymous (not verified) 216.106.236.82 MR Electric LLC Limited Liability Company 1853 230st Inwood, IA 51240 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. 2020-05-13 Matthew Rozeboom matt.rozeboom@gmail.com Inwood Lyon Iowa Rachel Schruers Caitlin Fluit Signed (1) The employer does not elect the employers’ liability coverage. Matt Rozeboom matt.rozeboom@gmail.com Owner/President Inwood Lyon Iowa Rachel Schruers Caitlin Fluit Signed
1448 2023-02-10 16:55 Anonymous (not verified) 94.188.205.177 Marks Nursery LLC Limited Liability Company 15008 310th Trl, Redfield, IA 50233 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. 2023-02-10 Susan L Jones sljoines026@gmail.com Redfield Dallas Iowa Douglas Jones Caitlin Zimmerman Signed (1) The employer does not elect the employers’ liability coverage. Donald Richardson DonR@phillipsassociatesins.net Agent Redfield Dallas Iowa Douglas Zimmerman Caitlin Zimmerman Signed
1423 2023-01-16 14:03 Anonymous (not verified) 173.224.19.200 Hoofin-It Proprietorship 86148 537th Ave. Plainview, NE 68769 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. 2023-01-16 Chase Terrill terrill365@gmail.com Pierce Pierce Nebraska Jim Aschoff Calan List Signed (1) The employer does not elect the employers’ liability coverage. Cole Aschoff aschoff_2@icloud.com Co-Owner Plainview Pierce Nebraska Jim Aschoff Calan List Signed
1091 2022-05-06 09:54 Anonymous (not verified) 97.127.228.168 American Concrete Proprietorship 2629 Sheffield dr. Davenport iowa 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. 2022-05-06 Craig wells craiglwells@hotmail.com Davenport Scott Iowa Kristin frymoyer Cameron anderson Signed (1) The employer does not elect the employers’ liability coverage. DK home products anne@dkhomeproducts.com Sub contractor Davenport Scott Iowa Kristin frymoyer Cameron anderson Signed
1430 2023-01-25 14:50 Anonymous (not verified) 104.222.82.50 Pille Ceramic Tile Proprietorship 17645 Guthrie 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. 2023-01-25 Bernie Pille blpille@yahoo.com Maple River Carroll IA Lisa Pille None Signed (1) The employer does not elect the employers’ liability coverage. Bernie Pille blpille@yahoo.com Self Maple River Carroll IA Lisa Pille Cameron Pille Signed
1886 2023-10-31 15:53 Anonymous (not verified) 94.188.205.176 CEM Businesses LLC Limited Liability Company 608 Evergreen Cir Nw Bondurant, IA 50035 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. 2023-10-31 Dane McDonald dane.mcdonald@stellar-solar.net Bondurant Polk Iowa Raelynn Aicher Cameron VanBuren Signed (1) The employer does not elect the employers’ liability coverage. Dane McDonald dane.mcdonald@stellar-solar.net Self Bondurant Polk Iowa Raelynn Aicher Cameron VanBuren Signed
1887 2023-10-31 15:57 Anonymous (not verified) 94.188.207.227 CEM BUSINESSES LLC Limited Liability Company 608 evergreen cir nw Bondurant, IA 50035 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. 2023-10-31 Dustin Rudolph dmrudo@gmail.com Des Moines Polk Iowa Raelynn Aicher Cameron VanBuren Signed (1) The employer does not elect the employers’ liability coverage. Dane McDonald dane.mcdonald@stellar-solar.net Self Bondurant Polk Iowa Raelynn Aicher Cameron VanBuren Signed