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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:
417 2021-03-03 13:49 Anonymous (not verified) 173.215.42.12 Lynx Ag LLC Limited Liability Company 510 H Ave, Churdan IA 50050 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. 2021-03-03 Lance Jeffrey Glendenning lanceandabby@wccta.net Churdan Greene Iowa Shelly L. Brus Dena M. Anderson Signed (1) The employer does not elect the employers’ liability coverage. Abby Glendenning accounting@lynxag.com Officer Churdan Greene Iowa Shelly L. Brus Dena M. Anderson Signed
418 2021-03-03 13:50 Anonymous (not verified) 173.215.42.12 Lynx Ag LLC Limited Liability Company 510 H Ave, Churdan IA 50050 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. 2021-03-03 Abigail Jayne Glendenning lanceandabby@wccta.net Churdan Greene Iowa Shelly L. Brus Dena M. Anderson Signed (1) The employer does not elect the employers’ liability coverage. Lance Jeffrey Glendenning lanceandabby@wccta.net President Churdan Greene Iowa Shelly L. Brus Dena M. Anderson Signed
971 2022-03-14 17:59 Anonymous (not verified) 207.32.37.48 Lynx Ag LLC Limited Liability Company 510 H Ave, Churdan, IA 50050 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. 2022-03-14 Lance Glendenning lanceandabby@wccta.net Churdan Greene Iowa Kim Kersey Shelly Brus Signed (1) The employer does not elect the employers’ liability coverage. Abby Glendenning accounting@lynxag.com Officer Churdan Greene Iowa Kim Kersey Shelly Brus Signed
972 2022-03-14 18:01 Anonymous (not verified) 207.32.37.48 Lynx Ag LLC Limited Liability Company 510 H Ave, Churdan, IA 50050 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. 2022-03-14 Abby Glendenning lanceandabby@wccta.net Churdan Greene Iowa Kim Kersey Shelly Brus Signed (1) The employer does not elect the employers’ liability coverage. Lance Glendenning lanceandabby@wccta.net President Churdan Greene Iowa Kim Kersey Shelly Brus Signed
828 2022-01-11 10:34 Anonymous (not verified) 74.215.151.63 Marr Arnold Planning Limited Liability Company 1328 California Ave. Ames Iowa 50014 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. 2022-01-11 Sarah Arnold sarahkarnold@gmail.com Cincinnati Hamilton Ohio April Humphreys Amy Burns Signed (1) The employer does not elect the employers’ liability coverage. Sarah Arnold sarah@marrarnoldplanning.com Self Cincinnati Hamilton Ohio Amy Burns April Humphreys Signed
2045 2024-02-15 10:26 Anonymous (not verified) 94.188.207.227 Francesco Martinez Proprietorship 403th 7th Ave NW Clarion IA 50525 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. 2024-02-15 Francesco Martinez Martinexfrancesco99@gmail.com Clarion Wright Iowa Jason W Helmers Josh W Helmers Signed (1) The employer does not elect the employers’ liability coverage. Francesco Martinez martinezfrancesco99@gmail.com Employer Clarion Wright Iowa Jason W Helmers Josh W Helmers Signed
1107 2022-05-16 15:28 Anonymous (not verified) 64.33.230.163 hangar 8 spray service Limited Liability Company 1626 airport dr 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. 2022-05-16 jed douglas hansen hangar.8@hotmail.com Clark South Dakota United States jed douglas hansen jed douglas hansen Signed (1) The employer does not elect the employers’ liability coverage. jed douglas hansen hangar.8@hotmail.com contract Clark South Dakota United States Jed Hansen Jed Hansen Signed
1110 2022-05-17 11:17 Anonymous (not verified) 64.33.230.163 Jed Hansen Proprietorship 1626 Airport Dr 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. 2022-05-17 Jed Douglas Hansen hangar.8@hotmail.com Clark Clark South Dakota Jed Hansen Jed Hansen Signed (1) The employer does not elect the employers’ liability coverage. Jed Hansen hangar.8@hotmail.com Proprietor Clark Clark South Dakota Jed Hansen Jed Hansen Signed
1111 2022-05-17 11:18 Anonymous (not verified) 64.33.230.163 Jed Hansen Proprietorship 1626 Airport Dr 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. 2022-05-17 Jed Douglas Hansen hangar.8@hotmail.com Clark Clark South Dakota Jed Hansen Jed Hansen Signed (1) The employer does not elect the employers’ liability coverage. Jed Hansen hangar.8@hotmail.com Proprietor Clark Clark South Dakota Jed Hansen Jed Hansen Signed
2018 2024-02-01 15:23 Anonymous (not verified) 94.188.205.177 SolQ, LLC Limited Liability Company 184 N 100 E STE A Logan, UT 84321 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. 2024-02-01 David Bean dave@solq.com Clarkston Cache Utah Perry M. Koger Rebecca Koger Signed (1) The employer does not elect the employers’ liability coverage. David Bean dave@solq.com Owner Logan Cache Utah Perry M. Koger Rebecca Koger Signed