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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:
1323 2022-09-28 22:45 Anonymous (not verified) 74.51.212.66 OUTDOOR MODERN CONCEPTS LLC Limited Liability Company 2520 RIVER MEADOWS DR., 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. 2022-09-28 CHRISTIAN RUBIO RUBIOCH39@GMAIL.COM DES MOINES POLK IOWA AMANDA DUPRE DARCI CLARK Signed (1) The employer does not elect the employers’ liability coverage. JENNIFER B. CHAVEZ-RIVERA JENNIFER.CHAVEZ-RIVERA@BROWNWINICK.COM ATTORNEY DES MOINES POLK IOWA AMANDA DUPRE DARCI CLARK Signed
956 2022-03-08 13:56 Anonymous (not verified) 72.13.16.196 Naprstek Media LLC Limited Liability Company 6505 Wellington Ln, 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. 2022-03-08 James Naprstek jimmy@kodiakcreative.com Dubuque Dubuque Iowa Trent Hanselmann Jonathan O'Brien Signed (1) The employer does not elect the employers’ liability coverage. Cheyenne Moseley services@e.legazoom.com Authorized Agent Glendale Los Angeles CA Trent Hanselmann Jonathan O'Brien Signed
2056 2024-02-24 08:17 Anonymous (not verified) 94.188.207.230 C&C Property LLC Limited Liability Partnership PO Box 418 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. 2024-02-24 Joshua Darwin Wessel wesselclublambs@gmail.com Kiron Crawford IA Chad D Foust Chad A Tweeten Signed (1) The employer does not elect the employers’ liability coverage. Chad Tweeten tweeten@hotmail.com Barn Manager 1099 employee Eagle grove Wright Iowa Chad Tweeten Chad Foust Signed
1184 2022-07-06 15:10 Anonymous (not verified) 149.20.238.108 Shelby County Fair Corporation Limited Liability Company 314 4th St. Harlan, IA 51537 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. 2022-05-06 Kaylee Goshorn shelbycountyfair@fmctc.com Harlan Shelby iowa Kate Heese Katie Petersen Signed (1) The employer does not elect the employers’ liability coverage. Kaylee Goshorn shelbycountyfair@fmctc.com Board Member Harlan Shelby Iowa Kate Heese Katie Petersen Signed
1185 2022-07-06 15:12 Anonymous (not verified) 149.20.238.108 Shelby County Fair Corporation Limited Liability Company 314 4th St. Harlan, IA 51537 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. 2022-05-06 Darren Goshorn shelbycountyfair@fmctc.com Harlan Shelby Iowa Kate Heese Katie Petersen Signed (1) The employer does not elect the employers’ liability coverage. Darren Goshorn shelbycountyfair@fmctc.com Board Member Harlan Shelby IA Kate Heese Katie Petersen Signed
1186 2022-07-06 15:49 Anonymous (not verified) 149.20.238.108 Shelby County Fair Corporation Limited Liability Company 314 4th St., Harlan, IA 51537 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. 2022-05-06 Lee Schoof shelbycountyfair@fmctc.com Harlan Shelby Iowa Kate Heese Katie Petersen Signed (1) The employer does not elect the employers’ liability coverage. Lee Schoof shelbycountyfair@fmctc.com Board Member harlan Shelby Iowa Kate Heese Katie Petersen Signed
1187 2022-07-06 15:51 Anonymous (not verified) 149.20.238.108 Shelby County Fair Corporation Limited Liability Company 314 4th St. Harlan, IA 51537 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. 2022-05-06 Kyle Manz shelbycountyfair@fmctc.com Harlan Shelby Iowa Kate Heese Katie Petersen Signed (1) The employer does not elect the employers’ liability coverage. Kyle Manz shelbycountyfair@fmctc.com Board Member Harlan Shelby Iowa Kate Heese Katie Petersen Signed
1349 2022-10-28 12:37 Anonymous (not verified) 173.26.153.59 spotlight drywall Proprietorship 1001 7th 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. 2022-06-01 paul woods spotlight.2008@hotmail.com Grundy Center Ia United States thuy do jaden do Signed (1) The employer does not elect the employers’ liability coverage. thuy do spotlight.2008@hotmail.com bookeeper Grundy Center Ia United States thuy do jaden do Signed
1867 2023-10-16 12:34 Anonymous (not verified) 94.188.205.176 North Bay Dock Service Proprietorship PO Box 374, Spirit Lake, IA 51360 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 Donald L. Johnson, Jr. djtjaj@outlook.com Spirit Lake Dickinson Iowa Michael Chozen April Bosma Signed (1) The employer does not elect the employers’ liability coverage. Teresa Johnson djtjaj@outlook.com bookkeeper Spirit Lake Dickinson Iowa Michael Chozen April Bosma Signed
1947 2023-12-07 16:01 Anonymous (not verified) 94.188.205.176 Reinier Construction LLC Limited Liability Company 1406 Linden Lane 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. 2023-12-07 David J Reinier reinierconst@aol.com Des Moines Polk IA PEGGY A ROHDE Douglas E Rohde Signed (1) The employer does not elect the employers’ liability coverage. PEGGY A ROHDE dnprohde@msn.com Bookkeeper Polk City Polk IA Douglas E Rohde Stacie L Miller Signed