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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:
188 2020-06-15 11:55 Anonymous (not verified) 67.60.42.173 SANDS CONSTRUCTION LLC Limited Liability Company 3812 Sioux River Rd 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. 2020-06-15 Ryan Sands rn_sands@hotmail.com Sioux City IA IA Nicole Sands Reese Sands Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Ryan Sands rn_sands@hotmail.com self/ Owner/ Operator Sioux City IA IA Nicole Sands Reese Sands Signed
191 2020-06-23 16:09 Anonymous (not verified) 173.18.3.76 Look At You LLC Limited Liability Company 5545 Mills Civic Pkwy Ste 100 West Des Moines, IA 50265 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. 2020-06-23 Amber Keppler keppler_ark@outlook.com Des Moines Polk IA Angela Kinsey Jon Stetzel Signed (1) The employer does not elect the employers’ liability coverage. Amber Keppler keppler_ark@outlook.com LLC Member Des Moines Polk IA Angela Kinsey Jon Stetzel Signed
197 2020-07-02 09:33 Anonymous (not verified) 66.188.136.150 M & EM Trucking Proprietorship 216 4th Ave SE Dyersville, IA 52040 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. 2020-07-02 Martin Funke kschumacher@tricorinsurance.com Dyersville Dubuque IA Russell Masartis Nancy Wortley Signed (1) The employer does not elect the employers’ liability coverage. Martin Funke kschumacher@tricorinsurance.com Same Dyersville Dubuque IA Russell Masartis Nancy Wortley 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
218 2020-07-27 19:24 Anonymous (not verified) 174.217.10.15 Bella Exteriors LLC Limited Liability Company 2908 Elm St, West Des Moines, IA 50265 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. 2020-07-27 Nicholas Andersen nick@rightroofing.com West Des Moines Polk IA Tasha Palacioz John Kha Signed (1) The employer does not elect the employers’ liability coverage. Nicholas Andersen nickande3564@gmail.com Self West Des Moines Polk IA Tasha Palacioz John Kha Signed
242 2020-08-24 09:27 Anonymous (not verified) 159.242.43.24 Bontreger Seamless Gutters Proprietorship 501 S Center St. Zearing Ia 50278 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. 2020-08-24 Harvey Bontreger borntrgerharvey@gmail.com Zearing Story Ia Alex G Meier Daniel Wunschel Signed (1) The employer does not elect the employers’ liability coverage. Harvey Bontreger borntrgerharvey@gmail.com Owner Zearing Story Ia Alex G Meier Daniel Wunschel Signed
243 2020-08-24 11:31 Anonymous (not verified) 159.242.43.24 Borntreger Seamless Gutters Proprietorship 501 S Center 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. 2020-08-24 Harvey Borntrager Borntregerharvey@gmail.com Zearing Story Ia Alex G Meier Daniel Wunschel Signed (1) The employer does not elect the employers’ liability coverage. Harvey Borntreger borntregerharvey@gmail.com Owner Zearing Story Ia Alex Meier Daniel Wunschel Signed
244 2020-08-25 13:32 Anonymous (not verified) 97.64.194.122 Soren Henriksen Proprietorship 2165 Roosevelt St., Dubuque, IA 52001 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. 2020-08-20 Soren Henriksen kschumacher@tricorinsurance.com Dubuque Dubuque IA Russell Masartis Nancy Wortley Signed (1) The employer does not elect the employers’ liability coverage. Soren Henriksen kschumacher@tricorinsurance.com Same Dubuque Dubuque IA Russell Masartis Nancy Wortley Signed
249 2020-08-28 13:06 Anonymous (not verified) 97.125.184.147 Supernova Construction LLC Proprietorship 4665 171st St, Urbandale, IA 50323 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. 2020-08-28 Heraclio A Ayala heraclio.ayala@yahoo.com Urbandale Dallas IA Ricardo Alverio Valentin Garcia Signed (1) The employer does not elect the employers’ liability coverage. Heraclio Ayala heraclio.ayala@yahoo.com Sole Member Urbandale Dallas IA Ricardo Alverio Valentin Garcia Signed
250 2020-09-01 12:08 Anonymous (not verified) 207.191.193.167 Jairo Varela Roofing Proprietorship 1681 Tofting Ave, Iowa City, IA 52240 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. 2020-01-01 Jairo Servellon Varela olvinlanza06@gmail.com Iowa City Johnson IA Jessica Lopez Anthony Johnson Signed (1) The employer does not elect the employers’ liability coverage. Jairo Varela olvinlanza06@gmail.com Same Iowa City Johnson IA Jessica Lopez Anthony Johnson Signed