1762 |
2023-07-26 12:42 |
Anonymous (not verified) |
94.188.207.230 |
Down Home Decor, Inc |
Proprietorship |
1021 2nd Ave SE Ste 200 - Dyersville, IA 52040 |
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. |
2023-07-26 |
Vicki Knipper |
jheims@english-insurance.com |
Dyersville |
IA |
IA |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
self agent |
Dyersville |
IA |
IA |
Joyce Heims |
Derrick Parsons |
Signed |
596 |
2021-08-04 10:48 |
Anonymous (not verified) |
184.80.177.137 |
Down Home Decor Inc |
Proprietorship |
1021 2nd Ave SE Ste 200 Dyersville, IA 52040 |
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. |
2021-08-04 |
Steve Knipper |
jheims@english-insurance.com |
Dyersville |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
1182 |
2022-07-06 13:40 |
Anonymous (not verified) |
50.80.25.116 |
Beast Construction LLC |
Limited Liability Company |
1025 O Ave NW |
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. |
2022-02-11 |
Gilberto Vasquez (GV Construction LLC) |
Normambazquez@gmail.com |
Iowa City |
IA |
United States |
Pedro Pinto |
Rafael Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Greg Saunders |
gsaunders@beastconstructioncr.com |
Owner |
CEDAR RAPIDS |
IA |
United States |
Laura Saunders |
Joanie Lacayo |
Signed |
1093 |
2022-05-12 06:32 |
Anonymous (not verified) |
50.80.25.116 |
Beast Construction LLC |
Limited Liability Company |
1025 O Ave NW, Cedar Rapids, IA 52405 |
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. |
2022-02-01 |
Catarino Martinez Alvarez - H&C Roofing LLC |
handc.rconst@outlook.com |
North Liberty |
Johnson |
Iowa |
Evelyn Lagos |
Edgardo Hernandez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Greg Saunders |
Gsaunders@beastconstructioncr.com |
Owner |
Cedar Rapids |
Linn |
Iowa |
Laura Sturm |
Joanie Lacayo |
Signed |
1333 |
2022-10-13 14:01 |
Anonymous (not verified) |
174.192.85.141 |
Terry Smith |
Proprietorship |
1028 14th Avenue Fulton il |
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. |
2022-10-14 |
Terry Smith |
terry1270smith@gmail.com |
Fulton |
IL |
United States |
Angela Smith |
Tracey Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Terry Smith |
terry1270smith@gmail.com |
Wife |
Fulton |
IL |
United States |
Angie Smith |
Tracey smith |
Signed |
928 |
2022-02-17 19:46 |
Anonymous (not verified) |
208.83.187.211 |
Eric Marsh Trucking LLC |
Limited Liability Company |
1029 Davis Ave Westbrook MN 56183 |
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. |
2022-02-17 |
Eric Marsh |
emt78@yahoo.com |
Westbrook |
Cottonwood |
MN |
Dustin Krick |
Sam Hansen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Eric Marsh |
emt78@yahoo.com |
Self |
Westbrook |
Cottonwood |
MN |
Dustin Krick |
Sam Hansen |
Signed |
1826 |
2023-08-30 16:38 |
Anonymous (not verified) |
94.188.207.227 |
IOWA MOLD REMOVAL |
Limited Liability Company |
103 15TH ST SW, ALTOONA, IA 50009 |
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. |
2023-08-30 |
RHETT OSELETTE |
RHETT.OSELETTE@GMAIL.COM |
CLIVE |
DALLAS |
IOWA |
ELLA OSELETTE |
MYA OSELETTE |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KATIE BROWN |
KATIE@IOWAMOLDREMOVAL.COM |
EMPLOYER |
ALTOONA |
POLK |
IOWA |
MYA OSELETTE |
ELLA OSELETTE |
Signed |
566 |
2021-07-08 14:19 |
Anonymous (not verified) |
50.82.130.211 |
Black Cat Ice Cream, LLC |
Limited Liability Company |
1031 Office Park Road, Suite #4, West Des Moines IA 50265 |
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. |
2021-06-10 |
David Boelman |
cmins_re@mchsi.com |
Des Moines |
Polk |
Iowa |
Mary Brown |
Kaytee Stearns |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Black Cat Ice Cream, LLC |
cmins_re@mchsi.com |
Self |
Des Moines |
Polk |
Iowa |
Mary Brown |
Kaytee Stearns |
Signed |
567 |
2021-07-08 14:22 |
Anonymous (not verified) |
50.82.130.211 |
Black Cat Ice Cream, LLC |
Limited Liability Company |
1031 Office Park Road, Suite #4, West Des Moines IA 50265 |
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. |
2021-06-10 |
Alex Carter |
cmins_re@mchsi.com |
Des Moines |
Polk |
Iowa |
Mary Brown |
Kaytee Stearns |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Black Cat Ice Cream, LLC |
cmins_re@mchsi.com |
Self |
Des Moines |
Polk |
Iowa |
Mary Brown |
Kaytee Stearns |
Signed |
2007 |
2024-01-29 13:13 |
Anonymous (not verified) |
94.188.205.174 |
Saratoga Seamless Gutters LLC |
Limited Liability Company |
10328 Howard Ave, Lime Springs, IA 52155 |
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 |
Michael Langlais |
saratogaseamlessgutters@gmail.com |
Lime Springs |
Howard |
IA |
Amanda Doty |
Michaela Langlais |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Langlais |
saratogaseamlessgutters@gmail.com |
Owner |
Lime Springs |
Howard |
IA |
Amanda Doty |
Michaela Langlais |
Signed |