1885 |
2023-10-29 08:05 |
Anonymous (not verified) |
94.188.207.223 |
MB Radon Services |
Limited Liability Company |
13206 State Hwy 2, Lamoni, Iowa, 50140 |
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. |
2023-10-29 |
Kyle Ramaeker |
raymaker83@gmail.com |
LAMONI |
IA |
United States |
Adam Boge |
Lance Webster |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kyle Ramaeker |
raymaker83@gmail.com |
Owner/Operator |
LAMONI |
IA |
United States |
Adam Boge |
Lance Webster |
Signed |
1884 |
2023-10-27 18:32 |
Anonymous (not verified) |
94.188.205.177 |
J&M dry wall |
Proprietorship |
948 Kern 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. |
2023-10-27 |
Melecio Zacarias-Cano |
Meleciozacarias29@gmail.com |
Waterloo |
Black hawk |
IA |
Luis flores |
Luis flores |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melecio Zacarias-Cano |
Meleciozacarias29@gmail.com |
Self |
Waterloo |
Black hawk |
IA |
Luis Flores |
Luis flores |
Signed |
1883 |
2023-10-27 10:49 |
Anonymous (not verified) |
94.188.207.228 |
Ron's SIding and Construction |
Proprietorship |
6097 26th 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. |
2023-10-27 |
Ron Heggebo |
heggebojessica@yahoo.com |
Vinton |
Benton |
IA |
Jessica Heggebo |
Jessica Heggebo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ron Heggebo |
heggebojessica@yahoo.com |
Self |
Vinton |
Benton |
IA |
Jessica Heggebo |
Jessica Heggebo |
Signed |
1882 |
2023-10-27 10:40 |
Anonymous (not verified) |
94.188.205.166 |
Ron's SIding and Construction |
Proprietorship |
6097 26th 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. |
2025-02-02 |
Ron Heggebo |
heggebojessica@yahoo.com |
Vinton |
Benton |
IA |
Jessica Heggebo |
Jessica Heggebo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ronnie Heggebo |
heggebojessica@yahoo.com |
self |
Vinton |
Benton |
IA |
Jessica Heggebo |
Jessica Heggebo |
Signed |
1881 |
2023-10-26 14:10 |
Anonymous (not verified) |
94.188.205.175 |
McAninch Painting LLC |
Limited Liability Company |
2422 Richmond 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. |
2023-10-26 |
Brian McAninch |
brian@allcoatfinishes.com |
Des Moines |
Polk |
Iowa |
Kane Fairman |
Brad Sandstoe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian McAninch |
brian@allcoatfinishes.com |
Self |
Des Moines |
polk |
Iowa |
Kane Fairman |
Brad Sandstoe |
Signed |
1880 |
2023-10-26 13:24 |
Anonymous (not verified) |
94.188.205.167 |
Brown Remodel & Construction LLC |
Limited Liability Company |
7819 Evans St Mingo iowa 50168 |
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. |
2023-10-26 |
Matthew Ray Brown |
brownremodel@gmail.com |
Mingo |
Jasper |
Iowa |
Rebecca Lynn Brown |
Michael Moore |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Ray Brown |
brownremodel@gmail.com |
Self |
Mingo |
Jasper |
Iowa |
Rebecca lynn Brown |
Michael Moore |
Signed |
1879 |
2023-10-26 13:17 |
Anonymous (not verified) |
94.188.207.224 |
CR Exteriors |
Proprietorship |
1636 Parktown Ct NE Unit 9 |
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. |
2023-10-26 |
corey becker |
cab222.ab@gmail.com |
cedar rapids |
linn |
iowa |
Brian Ashlock |
Brian Coover |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Corey Becker |
cab222.ab@gmail.com |
same |
Cedar Rapids |
Linn |
Iowa |
Brian Ashlock |
Brian Coover |
Signed |
1878 |
2023-10-26 09:06 |
Anonymous (not verified) |
94.188.205.168 |
Jones Facility Maintenance |
Limited Liability Company |
3929 Council Street NE |
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. |
2023-10-25 |
Mason Jones |
jonesmason546@gmail.com |
Cedar Rapids |
IA |
United States |
Lindsey Jones |
Seth Wennermark |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mason Bradley Jones |
jonesmason546@gmail.com |
Owner |
Cedar Rapids |
IA |
United States |
Lindsey Jones |
Seth Wennermark |
Signed |
1877 |
2023-10-23 15:49 |
Anonymous (not verified) |
94.188.207.228 |
Craig Michael Wilson |
Proprietorship |
24538 118th Street, Columbus Junction, IA 52738 |
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 |
Craig Michael Wilson |
tripod109@hotmail.com |
Columbus Junction |
Louisa |
IA |
Brenda Wilson |
Ruger Dean |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Craig Michael Wilson |
tripod109@hotmail.com |
Self |
Columbus Junction |
Louisa |
IA |
Brenda Wilson |
Ruger Dean |
Signed |
1876 |
2023-10-23 14:26 |
Anonymous (not verified) |
94.188.205.169 |
Magnus, LLC |
Limited Liability Company |
1120 2nd Street SE |
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. |
2023-10-23 |
Kristina Link |
magnina@aol.com |
Cedar Rapids |
IA |
IA |
Shannon Thompson |
Jeff Spies |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kristina Link |
magnina@aol.com |
business owner |
Cedar Rapids |
Iowa |
Iowa |
Shannon Thompson |
Jeff Spies |
Signed |