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Nonelection of Workers' Compensation or Employers' Liability Coverage

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Showing 81 - 90 of 2227.   Show 10 | 50 | 100 | 200 | 500 | 1000 | All results per page.
# 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:
48 2020-01-29 13:52 Anonymous (not verified) 97.64.170.98 DARIN J. KESSLER Proprietorship 1236 25TH ST AMES, IA 50010 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. 2020-01-29 DARIN J. KESSLER darinjkessler@gmail.com AMES STORY IOWA HEATHER DIANNE LANNING JENNY ANN ARENDS Signed (1) The employer does not elect the employers’ liability coverage. DARIN J. KESSLER darinjkessler@gmail.com SELF AMES STORY IOWA HEATHER DIANNE LANNING JENNY ANN ARENDS Signed
45 2020-01-28 16:13 Anonymous (not verified) 173.18.3.76 Delic Marble and Tile LLC Limited Liability Company 24 Ellefson Dr PO Box 413 DeSoto, IA 50069 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. 2020-01-31 Adin Delic delicgraniteandtile@gmail.com Adel Dallas Iowa Angela Kinsey Taylor Benshoof Signed (1) The employer does not elect the employers’ liability coverage. Lutfija Delic delicgraniteandtile@gmail.com LLC Member Adel Dallas Iowa Angela Kinsey Taylor Benshoof Signed
49 2020-01-31 12:53 Anonymous (not verified) 74.84.121.206 Cody Kleppe Proprietorship 1891 337th St Decorah IA 52101 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. 2020-01-31 Cody Kleppe darrele@ciains.biz Decorah Winneshiek Iowa Chris Fye Darrel Elsbernd Signed (1) The employer does not elect the employers’ liability coverage. Darrel Elsbernd darrele@ciains.biz agent Decorah Winneshiek Iowa Chris Fye Darrel Elsbernd Signed
57 2020-02-10 15:33 Anonymous (not verified) 198.167.182.164 AllEnhancements LLC Limited Liability Company 1122 Woodland Ln, LeClaire, IA 52753 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. 2020-01-31 Brett Allen allenhancementsllc@outlook.com LeClaire Scott Iowa Steven J Fishman E Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Brett Allen allenhancementsllc@outlook.com Managing Member LeClaire Scott Iowa Steven J Fishman E Dyan Kriener Signed
294 2020-10-28 10:08 Anonymous (not verified) 65.103.82.36 Des Moines Junk Proprietorship 3011 Dean Ave Des Moines IA 50317 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. 2020-01-31 Timothy Hall Sr. removal@dsmjunk.com Des Moines Polk Iowa eric johnson kayla artiolo Signed (1) The employer does not elect the employers’ liability coverage. Tim Hall removal@dsmjunk.com self des moines polk Iowa eric Kayla Signed
58 2020-02-10 21:18 Anonymous (not verified) 75.162.11.63 Moni tile Services llc Limited Liability Company 2207 E Walnut St des Moines iowa 50317 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. 2020-02-01 Monica M Sandoval Mjsandoval20@yahoo.com Des Moines Polk United States Cassie Ann bentz James wesley harkert Signed (1) The employer does not elect the employers’ liability coverage. Moni tile services llc Mjsandoval20@yahoo.com Self Des Moines Polk Iowa Cassie Ann bentz James wesley harkert Signed
78 2020-02-25 09:35 Anonymous (not verified) 65.127.131.118 Rey Construction, LLC Proprietorship 3317 Scott Ave Des Moines, iowa 50317 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. 2020-02-02 Juan Raymundo Hernandez reyano43@gmail.com Des Moines polk iowa Rigoberto Mayorga Y Bounv Quang Signed (1) The employer does not elect the employers’ liability coverage. Preferred Interior Construction INC dba PIC INC deb@piciowa.com PIC, INC-contractor, Rey Construction, LLC-subcontractor Altoona IA United States Martin Pinon Evan Bianchi Signed
59 2020-02-11 11:34 Anonymous (not verified) 198.167.182.164 Besch Electric LLC Limited Liability Company 317 Sycamore St, Riverside, IA 52327 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. 2020-02-03 Daniel Besch beschd@hotmail.com Riverside Washington Iowa Steven J Fishman E Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Daniel Besch beschd@hotmail.com Managing Member Riverside Washington Iowa Steven J Fishman E Dyan Kriener Signed
895 2022-02-04 11:57 Anonymous (not verified) 216.189.133.155 A1A Sandblasting (Iowa) Proprietorship 334 main street S.W. 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. 2020-02-04 michael d marjama mike.orie@yahoo.com menahga MN United States Josh Louviere Kevin Tomperi Signed (1) The employer does not elect the employers’ liability coverage. michael d marjama mike.orie@yahoo.com Owner menahga MN United States Josh Louviere Kevin Tomperi Signed
53 2020-02-06 11:09 Anonymous (not verified) 65.100.22.228 Bostian Captioning Service, Inc. Proprietorship 712 8th Avenue NE 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. 2020-02-06 Dana Bostian danabostian@msn.com Oelwein IA United States Lynne Koch Billie Winters Signed (1) The employer does not elect the employers’ liability coverage. Dana Bostian danabostian@msn.com President of Proprietorship Oelwein IA United States Lynne Koch Billie Winters Signed