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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:
632 2021-09-07 13:42 Anonymous (not verified) 50.82.130.211 Thomas Mann Proprietorship 401 Miners Street, Parkersburg, Iowa 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. 2021-09-09 Thomas Mann cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Thomas Mann cmins_re@mchsi.com Self Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed
634 2021-09-10 13:41 Anonymous (not verified) 173.23.145.231 julio medina Proprietorship 609 boyd st. des moines, iowa 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. (1) I am not electing the employers’ liability coverage. 2021-09-10 julio medina medinajulio10001@gmail.com des moines polk iowa jose rivas Virginia Gomez Signed (1) The employer does not elect the employers’ liability coverage. Julio Medina medinajulio10001@gmail.com owner des moines polk iowa jose Rivas Virginia Gomez Signed
636 2021-09-10 14:56 Anonymous (not verified) 173.19.179.111 SHANNON SUNDINE Proprietorship 513 16TH ST SPIRIT LAKE IA 51360 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. 2021-09-10 SHANNON SUNDINE SPSUNDINE@GMAIL.COM SPIRIT LAKE DICKINSON IOWA TAMI KLEIN JENNIFER YOUNG WIRTH Signed (1) The employer does not elect the employers’ liability coverage. SHANNON SUNDINE SPSUNDINE@GMAIL.COM SELF SPIRIT LAKE DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
638 2021-09-13 09:18 Anonymous (not verified) 74.84.91.178 Thomas Tremble Proprietorship 1209 University Avenue, Dubuque, IA 52001 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. 2021-08-09 Thomas Tremble TJTremble21@gmail.com Dubuque Dubuque Iowa Gabe Drewelow Derrick Parsons Signed (1) The employer does not elect the employers’ liability coverage. Thomas Tremble TJTremble21@gmail.com self Dubuque Dubuque Iowa Gabe Drewelow Derrick Parsons Signed
641 2021-09-17 09:16 Anonymous (not verified) 72.255.121.118 Osman Gonzalez-Sarceno Proprietorship 1403 Aspen Dr Adel, 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. 2021-09-17 Osman Gonzalez-Sarceno workorders@shoproyalflooring.com Des Moines Polk IA Melissa Bolanos Brianna Fuller Signed (1) The employer does not elect the employers’ liability coverage. Osman Gonzalez-Sarceno workorders@shoproyalflooring.com Owner Des Moines Polk Iowa Melissa Bolanos Brianna Fuller Signed
645 2021-09-18 09:47 Anonymous (not verified) 208.68.114.238 CHL Roofing & Siding Inc Proprietorship 509 1/2 E A St, West Liberty, IA 52776 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. 2021-09-18 Fabian Galvan Rodriguez fgalvanglez14@gmail.com West Liberty Muscatine Iowa Karina A Beltran Nereida Velez Signed (1) The employer does not elect the employers’ liability coverage. Fabian Galvan Rodriguez fgalvanglez14@gmail.com Self West Liberty Muscatine Iowa Karina A Beltran Nereida Velez Signed
647 2021-09-20 10:37 Anonymous (not verified) 173.29.34.49 Brandon Jones Proprietorship 2043 3x Avenue 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. 2021-09-20 Brandon Dederick Jones Kaleb0430jones@gmail.com East Moline United States Illinois Brandon Jones Brandon Jones Signed (1) The employer does not elect the employers’ liability coverage. Brandon Dederick Jones Kaleb0430jones@gmail.com self East Moline United States Illinois Brandon Jones Brandon Jones Signed
648 2021-09-21 10:03 Anonymous (not verified) 97.125.32.164 Manuel Morales Proprietorship 1302 13th St Des Moines, Iowa 50314 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. 2021-09-15 Manuel Morales deb@piciowa.com Des Moines Polk Iowa Deb Stratton Kelly Denger Signed (1) The employer does not elect the employers’ liability coverage. Manuel Morales deb@picowa.com subcontractor Des Moines Polk Iowa Deb Stratton Kelly Denger Signed
649 2021-09-21 13:15 Anonymous (not verified) 208.126.118.26 Wade Smith DBA WADA Farms Proprietorship 2428 270th st, Grand Mound, IA 52751 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. 2021-09-21 Wade Smith wade.smith1110@gmail.com Grand Mound Clinton Iowa Megan Fuglsang Jenny Gordon Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Wade Smith wade.smith1110@gmail.com self Grand Mound Clinton Iowa Megan Fuglsang Jenny Gordon Signed
654 2021-09-24 15:08 Anonymous (not verified) 199.247.64.87 Steve Porter DBA Precision Striping Proprietorship 408 Embassy Ct. Sergeant Bluff, IA 51054 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. 2021-09-23 Steve Porter steve.porter2710@gmail.com Sergeant Bluff Woodbury Iowa Josh Nichols Steve Porter Signed (1) The employer does not elect the employers’ liability coverage. Jana Reich JNeuzil@reichpainting.com Office Manager Sioux City Woodbury Iowa Josh Nichols Steve Porter Signed