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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:
834 2022-01-12 17:34 Anonymous (not verified) 67.212.111.166 Cory's Painting LLC Limited Liability Company Po Box 1161 Cedar Falls, Iowa 50613 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. 2021-01-13 Erik Bjorn Nelson ebjornnelson@gmail.com Waterloo Black Hawk County Iowa Kari Houle Steven John Swanson Signed (1) The employer does not elect the employers’ liability coverage. Cory Koger coryspainting@gmail.com Self Cedar Falls Black Hawk County Iowa Kari Houle Steven John Swanson Signed
835 2022-01-12 17:41 Anonymous (not verified) 67.212.111.166 Cory's Painting LLC Limited Liability Company Po Box 1161 Cedar Falls, Iowa 50613 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. 2022-01-13 Brian Christopher Armbruster crossespalms42@gmail.com Waterloo Black Hawk County Iowa Kari Houle Erik Bjorn Nelson Signed (1) The employer does not elect the employers’ liability coverage. Cory Koger coryspainting@gmail.com Self Cedar Falls Black Hawk County Iowa Kari Houle Erik Bjorn Nelson Signed
838 2022-01-13 17:53 Anonymous (not verified) 67.212.111.166 Cory's Painting LLC Limited Liability Company Po Box 1161 Cedar Falls, Iowa 50613 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. 2022-01-13 Darren Dean Fanning dschmanning@gmail.com Cedar Falls Black Hawk County Iowa Kari Houle Braden L Gray Signed (1) The employer does not elect the employers’ liability coverage. Cory Allen Koger coryspainting@gmail.com Self Cedar Falls Black Hawk County Iowa Kari Houle Braden L Gray Signed
2183 2024-04-26 14:49 Anonymous (not verified) 94.188.205.168 Cory's Painting LLC Limited Liability Company Po Box 1161 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. 2024-04-01 Jared Birkenholz jareddrewb@gmail.com CEDAR FALLS IA United States Colton Blue Kari Houle Signed (1) The employer does not elect the employers’ liability coverage. Cory Koger coryspainting@gmail.com Self CEDAR FALLS IA United States Colton Blue Kari Houle Signed
2184 2024-04-26 15:03 Anonymous (not verified) 94.188.205.166 Cory's Painting LLC Limited Liability Company Po Box 1161, Cedar Falls, Iowa 50613 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. 2024-04-15 Joseph Abrahamson abrahamsonjd95@gmail.com Readlyn Bremer United States Colton Blue Kari Houle Signed (1) The employer does not elect the employers’ liability coverage. Cory Koger coryspainting@gmail.com Self Cedar Falls Blackhawk Iowa Colton Blue Kari Houle Signed
324 2020-11-20 09:08 Anonymous (not verified) 71.39.227.238 County-Line Construction, LLC Limited Liability Company 314 NE 2nd St, Panora, IA 50216 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. 2020-11-20 John Steve Vogel thevogels@netins.net Panora Guthrie Iowa Steve Phillips Abbey Luellen Signed (1) The employer does not elect the employers’ liability coverage. John Steve Vogel thevogels@netins.net Owner Panora Guthrie Iowa Steve Phillips Abbey Luellen Signed
1374 2022-11-17 14:33 Anonymous (not verified) 72.106.129.202 Cowman Consulting and Construction LLC Limited Liability Company 740 NE Horizon Dr, Waukee IA 50263 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. 2022-11-17 Khalid Cowman khalidcowman1@gmail.com Waukee Dalls Iowa Charlotte Rasmussen Austin Miller Signed (1) The employer does not elect the employers’ liability coverage. Khalid Cowman khalidcowman1@gmail.com Self/Owner Waukee Dallas Iowa Charlotte Rasmussen Austin Miller Signed
615 2021-08-20 16:22 Anonymous (not verified) 50.81.152.147 CPIA Home Specialists LLC Limited Liability Company 1214 13th 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. 2021-08-20 Melvin Benitez Benitezmelvin0@gmail.com Des Moines Iowa United States Salvador Benitez Zoila Benitez Signed (1) The employer does not elect the employers’ liability coverage. Melvin Benitez Benitezmelvin0@gmail.com Owner Des Moines Iowa United States Salvador Benitez Zoila Benitez 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
1627 2023-05-08 13:43 Anonymous (not verified) 94.188.205.169 CR TOTAL PLUMBING, INC. Limited Liability Company 8190 Southern Hills Circle, Dubuque, IA 52003 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. 2023-05-05 Cory Ranson crpipes2@yahoo.com Dubuque Dubuque Iowa Randi Taylor Michelle Woodman Signed (1) The employer does not elect the employers’ liability coverage. CR Total Plumbing, Inc crpipes2@yahoo.com Owner Dubuque Dubuque Iowa Randi Taylor Michelle Woodman Signed