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  1. Nonelection of Workers' Compensation or Employers' Liability Coverage
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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:
1810 2023-08-21 10:18 Anonymous (not verified) 94.188.207.224 Vicente McCain Proprietorship 524 panama st Nashua 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. 2023-08-20 Jose V Mccain Vic_mccain@yahoo.com Nashua IA United States Rafael McCain Jessica McCain Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jose V Mccain Vic_mccain@yahoo.com Brother Nashua IA United States Rafael McCain Jessica McCain Signed
1809 2023-08-21 07:55 Anonymous (not verified) 94.188.207.228 Gonzalez Drywall LLC Limited Liability Company 323 Friendhip St Apt 3, Iowa City, IA 52245 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. 2023-08-21 Leonel Angel Gonzalez victorangel8373@gmail.com Iowa City Johnson Iowa Chris Hay Brad Bower Signed (1) The employer does not elect the employers’ liability coverage. Leonel Angel Gonzalez victorangel8373@gmail.com Self Iowa City Johnson Iowa Chris Hay Brad Bower Signed
1808 2023-08-17 17:17 Anonymous (not verified) 94.188.205.168 Treimer Trucking LLC Limited Liability Company 3277 102nd St. Durant, IA 52747-9524 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. 2023-08-17 Daniel Dennis Treimer dtreimer65@gmail.com Tipton Iowa United States Sydney Rae Lane Spencer Lea Parsons Signed (1) The employer does not elect the employers’ liability coverage. Daniel Dennis Treimer dtreimer65@gmail.com Self Tipton Iowa United States Syndey Rae Lane Spencer Lea Parsons Signed
1807 2023-08-17 12:45 Anonymous (not verified) 94.188.205.175 LONE STAR ROOFING, LLC Limited Liability Company 4021 WINDSOR CT DES MOINES, IA 50320 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. 2023-08-17 RAQUEL B DIAZ MENENDEZ LONE.STAR.ROOFING76@GMAIL.COM DES MOINES USA IOWA LILIANA SANCHEZ RENE ALEXANDER VELASCO Signed (1) The employer does not elect the employers’ liability coverage. LONE STAR ROOFING, LLC LONE.STAR.ROOFING76@GMAIL.COM MEMBER OWNER DES MOINES USA IOWA LILIANA SANCHEZ RENE ALEXANDER VELASCO Signed
1806 2023-08-17 11:37 Anonymous (not verified) 94.188.207.229 OKOBOJI TSHIRT CENTER LLC Limited Liability Company PO BOX 158 ARNOLDS PARK, IA 51331 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. 2023-08-16 YACCOB SEBAN PACIFIC513@YAHOO.COM ARNOLDS PARK DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. YAACOB SEBAN PACIFIC513@YAHOO.COM SELF ARNOLDS PARK DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1805 2023-08-17 10:00 Anonymous (not verified) 94.188.207.229 Polly Pattison Sewing LLC Limited Liability Company 6917 New York 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. 2023-08-17 Polly Pattison pollypattison@msn.com Urbandale Polk IA Lynn Niceswanger Louise Anderson Signed (1) The employer does not elect the employers’ liability coverage. Polly Pattison pollypattison@msn.com Same Urbandale Polk Iowa Lynn Niceswanger Louise Anderson Signed
1804 2023-08-16 18:22 Anonymous (not verified) 94.188.207.226 Zach Moyle Masonry Limited Liability Company 7222 Great River Rd 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. 2023-08-16 Zach Moyle zmoylemasonry@gmail.com Clermont FAYETTE FAYETTE Brittney Loyd Dave Moyle Signed (1) The employer does not elect the employers’ liability coverage. Zach Moyle zmoylemasonry@gmail.com Self Clermont FAYETTE FAYETTE Brittney Loyd Dave Moyle Signed
1803 2023-08-15 19:03 Anonymous (not verified) 94.188.207.224 Teimer Trucking LLC Limited Liability Company 3277 102nd St. Durant, IA 52747-9524 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. 2023-08-15 Daniel Dennis Treimer dtreimer65@gmail.com Tipton Iowa United States Spencer Lea Parsons Sydney Rae Lane Signed (1) The employer does not elect the employers’ liability coverage. Daniel Dennis Treimer dtreimer65@gmail.com Self Tipton Iowa United States Spencer Lea Parsons Sydney Rae Lane Signed
1802 2023-08-15 15:23 Anonymous (not verified) 94.188.205.174 NORTH STARS, LLC Limited Liability Company 4374 STATE ST STE 2 BETTENDORF, IA 52722 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. 2023-08-15 JOSE A DURAN MORALES northstarsllcmn@gmail.com BETTENDORF USA IOWA ARMANDO DURAN LILIANA SANCHEZ Signed (1) The employer does not elect the employers’ liability coverage. NORTH STARS, LLC northstarsllcmn@gmail.com BUSINESS OWNER BETTENDORF USA IOWA LILIANA SANCHEZ ARMANDO DURAN Signed
1801 2023-08-15 14:17 Anonymous (not verified) 94.188.205.168 Mark S Lisiecki Proprietorship 2526 S Arizona RD Apache Junction AZ 85119 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. 2023-08-15 Mark S Lisiecki markslisiecki@yahoo.com Apache Junction PINAL Arizona Simona Valeriano Cindy Ugarte Signed (1) The employer does not elect the employers’ liability coverage. Mark Lisiecki markslisiecki@yahoo.com owner APACHE jUNCTION PINAL AZ Simona Valeriano Cindy Ugarte Signed