1235 |
2022-08-01 17:22 |
Anonymous (not verified) |
129.222.1.151 |
KRG Gutters |
Limited Liability Company |
20376 Whiskey Rdg Ottumwa, Ia 52501 |
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. |
2022-08-01 |
Robert M Galey |
rsgaley24@yahoo.com |
Ottumwa |
IA |
United States |
Stacey Galey |
Kinnick Galey |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert M Galey |
rsgaley24@gmail.com |
Self |
Ottumwa |
IA |
United States |
Stacey Galey |
Kinnick Galey |
Signed |
1221 |
2022-07-21 13:40 |
Anonymous (not verified) |
129.222.3.107 |
Barkers Handyman Express |
Proprietorship |
120 S Mill St Gilman, IA 50106 |
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. |
2022-07-22 |
Devin Levi Barker |
devinbarker91@gmail.com |
Gilman |
Marshall |
Iowa |
Emily Anne Barker |
Lloyd Owen Barker Jr. |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Devin Levi Barker |
devinbarker91@gmail.com |
Owner |
Gilman |
Marshall |
IA |
Emily Anne Barker |
Lloyd Owen Barker Jr. |
Signed |
1015 |
2022-03-29 10:56 |
Anonymous (not verified) |
129.255.1.117 |
Alli Center |
Proprietorship |
1150 5th St Suite 270 Coralville, IA 52241 |
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. |
2022-03-29 |
Miranda K Maday |
miranda.maday@alli-center.com |
North Liberty |
Johnson |
Iowa |
Zara Wanlass |
Jason Knight |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Zara Wanlass |
zara.wanlass@alli-center.com |
Co-Owner and Business Manager |
Iowa City |
Johnson |
IA |
Miranda K Maday |
Jason Knight |
Signed |
1378 |
2022-11-21 15:12 |
Anonymous (not verified) |
136.34.59.85 |
Jake Jones |
Proprietorship |
203 9th Ave. Colona, Il 61241 |
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. |
2022-11-21 |
Jake Jones |
jmjones807@gmail.com |
Colona |
Henry |
Illinois |
Jordan Nisiewicz |
Jordan Loyd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Regional Recruiter |
Kansas City |
Clay |
Missouri |
Jordan Loyd |
Daniel Neal |
Signed |
1391 |
2022-12-12 11:13 |
Anonymous (not verified) |
136.35.255.41 |
Snyder Roofing |
Proprietorship |
2343 ridge trail ne cedar rapids ia 52402 |
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. |
2022-12-12 |
Craig Snyder |
snyderroofingcr@gmail.com |
Cedar Rapids |
Linn county |
Iowa |
Jordan Loyd |
Charles Wood |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Clay |
Missouri |
Charles Wood |
Jordan Loyd |
Signed |
1429 |
2023-01-25 13:43 |
Anonymous (not verified) |
136.35.255.41 |
J&D Renovations |
Proprietorship |
114 2nd St. Carbon Cliff, IL 61239 |
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. |
2023-01-25 |
Donald Lane |
jdrenovations309@gmail.com |
Carbon Cliff, IL |
Rock Island County |
Illinois |
Jordan Nisiewicz |
Cody Dunbar |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Clay |
Missouri |
Jordan Loyd |
Cody Dubar |
Signed |
122 |
2020-04-15 18:10 |
Anonymous (not verified) |
136.37.174.39 |
Merge Midwest Engineering, LLC |
Limited Liability Company |
2668 W. Catalpa Street, Olathe, KS 66061 |
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. |
2020-04-15 |
Janelle Marie Clayton |
jclayton@mergemidwest.com |
Olathe |
Johnson |
Kansas |
David Jahner |
Patrick McCartney |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Janelle Marie Clayton |
jclayton@mergemidwest.com |
Self |
Olathe |
Johnson |
Kansas |
David Jahner |
Patrick McCartney |
Signed |
281 |
2020-10-20 08:58 |
Anonymous (not verified) |
136.37.174.39 |
Merge Midwest Engineering, LLC |
Limited Liability Company |
2668 W Catalpa Street, Olathe, KS 66061 |
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. |
2020-10-20 |
Michael Lee Baer |
lbaer@mergemidwest.com |
Louisburg |
Miami |
Kansas |
Heather Lee Baer |
Ami Bowes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Janelle Marie Clayton |
jclayton@mergemidwest.com |
Self |
Olathe |
Johnson |
Kansas |
Patrick McCartney |
David Jahner |
Signed |
211 |
2020-07-20 15:30 |
Anonymous (not verified) |
138.43.237.249 |
High Caliber Fiber |
Limited Liability Company |
2958 110th Ave Masonville IA 50654 |
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. |
2020-07-20 |
Chris |
Chris_cooepr@highcaliberfiber.com |
masonville |
Delaware |
IA |
NIck Beranek |
Nicole KIntzle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chris Cooper |
Chris_cooper@highcaliberfiber.com |
Self |
Masonville |
Delaware |
IA |
Nick Beranek |
Nicole Kintzle |
Signed |
1160 |
2022-06-20 10:08 |
Anonymous (not verified) |
138.43.237.249 |
High Caliber Fiber |
Limited Liability Company |
2958 110th ave masonville IA, 50654 |
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. |
2022-06-20 |
chris cooper |
Chris_cooper@highcaliberfiber.com |
Masonville |
Delaware |
IA |
Laura Rose Lentz |
Blake Dean Elbert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chris Cooper |
Chris_cooper@highcaliberfiber.com |
self |
Masonville |
Delaware |
IA |
Laura Rose Lentz |
BLake Dean Elbert |
Signed |