2218 |
2024-05-09 16:20 |
Anonymous (not verified) |
94.188.205.167 |
Brenda Riseley |
Proprietorship |
2265 Copper Wynd Drive, Pleasant Hill Iowa 50327 |
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. |
2024-05-09 |
Brenda Riseley |
riseleybrenda@gmail.com |
Pleasant Hill |
IA |
United States |
Brenda Riseley |
Brenda Riseley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brenda Riseley |
riseleybrenda@gmail.com |
Self |
Pleasant Hill |
IA |
United States |
David Bottino |
Aubrey Stith |
Signed |
2217 |
2024-05-09 14:28 |
Anonymous (not verified) |
94.188.207.224 |
Emmanual A Sanchez Chavez |
Proprietorship |
7301 Fleur Dr, Lot 10, Des Moines, IA 50325 |
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. |
2024-05-09 |
Emmanuel A Sanchez Chaves |
alexsanchw3@gmail.com |
Des Moines |
Polk |
Iowa |
Jesus Garcia |
Fabion Dalgato |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Emmanuel A Sanchez Chavez |
alexsanchw3@gmail.com |
Person |
Des Moines |
Polk |
Iowa |
Jesus Garcia |
Fabion Dalgato |
Signed |
2216 |
2024-05-09 11:51 |
Anonymous (not verified) |
94.188.207.229 |
Imhoff Innovations LLC |
Limited Liability Company |
108 Cherry Lane 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. |
2024-05-09 |
Jediah Imhoff |
jedimhoff@gmail.com |
Riverside |
IA |
United States |
Jordan Nisiewicz |
Jordan Lyod |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Regional Recruiter |
Kansas City |
Johnson |
MO |
Jordan Lyod |
Jediah Imhoff |
Signed |
2215 |
2024-05-08 22:07 |
Anonymous (not verified) |
94.188.207.223 |
Self Employed-Ryan Thornton |
Proprietorship |
8403 Horton Ave Urbandale IA 50322 |
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. |
2024-05-08 |
Ryan M Thornton |
rt6366155@gmail.com |
Urbandale |
Polk |
Iowa |
April Oxendale |
Bruce Thornton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Thornton |
rt6366155@gmail.com |
Self |
Urbandale |
Polk |
Iowa |
April Oxendale |
Bruce Thornton |
Signed |
2214 |
2024-05-08 13:49 |
Anonymous (not verified) |
94.188.205.168 |
Hagen Installation Solutions LLC |
Limited Liability Company |
725 Cole St Carlisle, IA 50047 |
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. |
2024-05-08 |
Clay Allen Hagen |
clay.hagenson@gmail.com |
Carlisle |
Warren |
Iowa |
Tyler Bumgardner |
Spencer Kissinger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Clay Allen Hagen |
clay.hagenson@gmail.com |
Same person |
Carlisle |
Warren |
Iowa |
Tyler Bumgardner |
Spencer Kissinger |
Signed |
2213 |
2024-05-08 13:37 |
Anonymous (not verified) |
94.188.205.174 |
Timothy strong |
Limited Liability Company |
615 61street |
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. |
2024-05-08 |
Timothy Dewayne strong jr |
timothystrong33@gmail.com |
Davenport iowa |
USA |
Iowa |
Thomasina hunter |
Tyletha dates |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy strong painting |
timothystrong33@gmail.com |
Friend |
Davenport |
Usa |
Iowa |
Thomasina hunter |
Tyletha dates |
Signed |
2212 |
2024-05-08 13:26 |
Anonymous (not verified) |
94.188.207.224 |
Lifetime Roofing Installations, LLC |
Limited Liability Company |
703 2nd St. SW Tripoli, IA 50676 |
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. |
2024-05-08 |
Kurtis Walvatne |
lifetimeroofing12@yahoo.com |
Tripoli |
Bremer |
Iowa |
Mike Meyer |
Kelly Walvatne |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kurtis Walvatne |
lifetimeroofing12@yahoo.com |
Owner |
Tripoli |
Bremer |
Iowa |
Mike Meyer |
Kelly Walvatne |
Signed |
2211 |
2024-05-08 12:39 |
Anonymous (not verified) |
94.188.207.227 |
Barron Carpentry & Renovations LLC |
Limited Liability Company |
1925 E 29th St. 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. |
2024-05-07 |
Guillermo Barron |
barroncarpentry.renovations@gmail.com |
Des Moines |
POLK |
IOWA |
Abigail Hernandez Colima |
Diane Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Registered Agents INC. |
agent@iowaregisteredagent.com |
Registered agent |
Waterloo |
Black Hawk |
IOWA |
Abigail Hernandez Colima |
Diane Garcia |
Signed |
2210 |
2024-05-07 19:15 |
Anonymous (not verified) |
94.188.207.229 |
Greenelectric |
Proprietorship |
407 Drury 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. |
2024-05-07 |
Harold Carr |
handbcarr@hotmail.com |
Legrad |
Iowa |
Iowa |
Harold Dale Carr |
Harold Dale Carr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Harold Carr |
handbcarr@hotmail.com |
I am the owner |
Legrad |
Iowa |
Iowa |
Harold Dale Carr |
Harold Dale Carr |
Signed |
2209 |
2024-05-07 15:03 |
Anonymous (not verified) |
94.188.207.225 |
THE FURNITURE GIRL LLC |
Limited Liability Company |
19257 CONIFER LN COUNCIL BLUFFS, IA 51503 |
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. |
2024-05-07 |
PATTI WIGGINS |
pwiggins@npdodge.com |
VILLISCA |
MONTGOMERY |
IA |
NATHAN HULL |
JESSICA GARDNER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
PATTI WIGGINS |
pwiggins@npdodge.com |
SELF |
VILLISCA |
MONTGOMERY |
IA |
NATHAN HULL |
JESSICA GARDNER |
Signed |
2208 |
2024-05-07 12:44 |
Anonymous (not verified) |
94.188.205.169 |
Tom Franklin |
Proprietorship |
2353 Salem Road, New London, IA 52645 |
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. |
2024-05-07 |
Thomas Eric Franklin |
68carpetman@gmail.com |
New London |
Henry |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Thomas Eric Franklin |
68carpetman@gmail.com |
owner |
New London |
Henry |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
2207 |
2024-05-07 09:44 |
Anonymous (not verified) |
94.188.207.226 |
Rodrimart brothers corp |
Limited Liability Company |
958 8th ave nw Altoona 50009 |
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. |
2024-05-07 |
Enrique Rodriguez |
carluto_1983@hotmail.com |
Altoona |
Polk |
Iowa |
Adan boge |
Lonce wester |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Enrique Rodriguez |
carluto_1983@hotmail.com |
President |
Altoona |
Polk |
Iowa |
Adan boge |
Leans wester |
Signed |
2206 |
2024-05-07 09:10 |
Anonymous (not verified) |
94.188.205.166 |
Stephanie Farmer |
Proprietorship |
600 6th Ave, Marion, IA 52302 |
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. |
2024-05-07 |
Stephanie Farmer |
farmer.stephanie22@gmail.com |
Marion |
Linn |
IA |
Chris Farmer |
Deb Hartz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stephanie Farmer |
farmer.stephanie22@gmail.com |
Self |
Marion |
Linn |
IA |
Chris Farmer |
Deb Hartz |
Signed |
2205 |
2024-05-07 08:56 |
Anonymous (not verified) |
94.188.207.227 |
MILLER CONSTRUCTION SIDING & WINDOWS, LLC |
Limited Liability Company |
3104 SW 26TH STREET, ANKENY, IA. 50023 |
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. |
2024-05-07 |
SCOTT MICHAEL DORAU |
scott@millersidingandwindows.com |
ANKENY |
POLK |
IOWA |
ADAM BOGE |
LANCE WEBSTER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SCOTT MICHAEL DORAU |
scott@millersidingandwindows.com |
OWNER |
ANKENY |
POLK |
IOWA |
ADAM BOGE |
LANCE WEBSTER |
Signed |
2204 |
2024-05-06 18:56 |
Anonymous (not verified) |
94.188.205.168 |
Jim saukko |
Proprietorship |
13232 nw 30 th 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. |
2024-05-05 |
Jim Saukko |
saukkogt500@gmail.com |
Polk city |
IA |
United States |
Dawn brown |
Kirk moser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jim Saukko |
saukkogt500@gmail.com |
Self |
Polk city |
IA |
IA |
Dawn brown |
Kirk moser |
Signed |
2203 |
2024-05-06 12:44 |
Anonymous (not verified) |
94.188.207.228 |
Cma landimprovments |
Limited Liability Company |
530 50th pleasantville |
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. |
2024-05-06 |
Cody authier |
cauthier85@gmail.com |
Pleasantville |
Marion |
Iowa |
Melissa authier |
Valerie vanhelten |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cody authier |
cauthier85@gmail.com |
Self |
Pleasantville |
Marion |
Iowa |
Melissa authier |
Valerie vanhelten |
Signed |
2202 |
2024-05-06 11:36 |
Anonymous (not verified) |
94.188.207.224 |
Neil Wedeking |
Proprietorship |
408 Maple St, Nemaha, IA 50567 |
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. |
2024-05-06 |
Neil Douglas Wedeking |
nandjwedeking@frontiernet.net |
Nemaha |
Sac |
Iowa |
Joseph McCollum |
Heather Husman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Neil Wedeking |
nandjwedeking@frontiernet.net |
Self |
Nemaha |
Sac |
Iowa |
Joseph Paul McCollum |
Heather Lee Husman |
Signed |
2201 |
2024-05-06 10:42 |
Anonymous (not verified) |
94.188.207.226 |
Trent Hatlen |
Proprietorship |
1042 490th Street, Rembrandt, IA 50576 |
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. |
2024-05-06 |
Trent Hatlen |
trentgotti@yahoo.com |
Rembrandt |
Buena Vista |
Iowa |
Jared Brashears |
Katie Gunkelman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Trent Hatlen |
trentgotti@yahoo.com |
Owner |
Rembrandt |
Buena Vista |
Iowa |
Jared Brashears |
Katie Gunkelman |
Signed |
2200 |
2024-05-06 08:46 |
Anonymous (not verified) |
94.188.207.226 |
Dominguez Construction LLC |
Limited Liability Company |
1680 East Emma 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. |
2024-05-05 |
Ramon Dominguez |
3memincolina@gmail.com |
Des Moines |
Polk |
Iowa |
Nathan Miller |
Stacey Lazear |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ramon Dominquez |
3memincolina@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Nathan Miller |
Stacey Lazear |
Signed |
2199 |
2024-05-03 13:27 |
Anonymous (not verified) |
94.188.207.228 |
Polar Delights LLC DBA Twists Ice Cream |
Limited Liability Company |
110 S 9th Ave Eldridge IA 52748 |
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. |
2024-05-03 |
Anna Kokity |
amkokity@gmail.com |
Moline |
Rock Island |
IL |
Ashley Schwien |
Kasey Lange |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Anna Kokity |
amkokity@gmail.com |
self |
Moline |
Rock Island |
IL |
Ashley Schwien |
Kasey Lange |
Signed |
2198 |
2024-05-02 11:26 |
Anonymous (not verified) |
94.188.207.224 |
Sierra Stone LLC |
Limited Liability Company |
2504 E 37th St 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. |
2024-05-02 |
Daniel Nunez |
danieln2024@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Nunez |
danieln2024@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2197 |
2024-05-02 09:30 |
Anonymous (not verified) |
94.188.207.229 |
Melvin Osorio |
Proprietorship |
3848 E 14th St Trlr 78, Des Moines IA 50313 |
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. |
2024-05-02 |
Melvin Osorio |
matamorosana56@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melvin Osorio |
matamorosana56@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2196 |
2024-05-01 09:18 |
Anonymous (not verified) |
94.188.207.230 |
Penaloza Stone LLC |
Limited Liability Company |
1530 8th St Des Moines IA 50314 |
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. |
2024-05-01 |
Javier Marcial Penaloza |
javiermarcial.jmp@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Javier Marcial Penaloza |
javiermarcial.jmp@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2195 |
2024-04-30 15:31 |
Anonymous (not verified) |
94.188.205.166 |
Jason Cooper |
Proprietorship |
1181 Western Ave Stockton Iowa 52769 |
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. |
2024-04-30 |
Jason cooper |
jvcpainting88@gmail.com |
Stockton |
IA |
United States |
Violet minssen |
Hope Bishop |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jason cooper |
jvcpainting88@gmail.com |
Self |
Stockton |
IA |
United States |
Violet minssen |
Hope Bishop |
Signed |
2194 |
2024-04-30 14:57 |
Anonymous (not verified) |
94.188.207.223 |
Juan Raymundo Hernandez |
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. |
2024-01-25 |
Juan Raymundo Hernandez |
deb@piciowa.com |
Des Moines |
Poik |
Iowa |
Kelly Denger |
Debra Stratton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Juan Raymundo Hernandez |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Kelly Denger |
Debra Stratton |
Signed |
2193 |
2024-04-30 11:37 |
Anonymous (not verified) |
94.188.205.168 |
Hausman Dozing LLC |
Limited Liability Company |
24860 230th St Carroll, Iowa 51401 |
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. |
2024-04-30 |
Jess Jonathan Hausman |
hausmandozing@gmail.com |
Carroll |
Carroll |
IOWA |
Jeff Dentlinger |
Lauren Brauckman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jess Hausman |
hausmandozing@gmail.com |
Owner |
Carroll |
Carroll |
IOWA |
Jeff Dentlinger |
Lauren Brauckman |
Signed |
2192 |
2024-04-29 13:15 |
Anonymous (not verified) |
94.188.205.166 |
ElmStreet Apothecary |
Limited Liability Company |
320 W Kimberly Road #227 |
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. |
2024-04-29 |
Erica McGee |
esalsbury07@gmail.com |
Bettendorf |
Scott |
Ia |
Jennifer West |
Julie Francis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Erica McGee |
esalsbury07@gmail.com |
Self |
Bettendorf |
Scott |
Ia |
Jennifer West |
Julie Francis |
Signed |
2191 |
2024-04-29 10:09 |
Anonymous (not verified) |
94.188.207.225 |
Anthony Rakestraw |
Proprietorship |
1262 S Kellogg St., Galesburg, IL 61401 |
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. |
2024-04-29 |
Anthony Rakestraw |
gazzork2@yahoo.com |
Galesburg |
Know |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Anthony Rakestraw |
gazzork2@yahoo.com |
owner |
Galesburg |
Knox |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
2190 |
2024-04-29 09:28 |
Anonymous (not verified) |
94.188.205.168 |
JOHNSON OHANA LLC |
Limited Liability Company |
145 GREENBRIER DR, BURLINGTON, IA 52601 |
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. |
2024-04-29 |
JARED JOHNSON |
KONAOHANAICE@GMAIL.COM |
BURINGTON |
DES MOINES |
IOWA |
MARCY KNAUSS |
MATTHEW RINKER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MAGGIE JOHNSON |
KONAOHANAICE@GMAIL.COM |
PARTNER/SPOUSE |
BURLINGTON |
DES MOINES |
IOWA |
MARCY KNAUSS |
MATTHEW RINKER |
Signed |
2189 |
2024-04-29 09:23 |
Anonymous (not verified) |
94.188.207.225 |
Sals Home Improvements LLC |
Limited Liability Company |
3750 NW Maple Ct Ankeny IA 50023 |
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. |
2024-04-29 |
Salvador Gomez |
salvadorg27@hotmail.com |
Ankeny |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Salvador Gomez |
salvadorg27@hotmail.com |
Self |
Ankeny |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2188 |
2024-04-29 09:05 |
Anonymous (not verified) |
94.188.207.229 |
General Lee Franklin |
Proprietorship |
820 Oak Street, Burlington, IA 52601 |
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. |
2024-04-25 |
General Lee Franklin |
gleef1966@gmail.com |
Burlington |
Des Moines |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
General Lee Franklin |
gleef1966@gmail.com |
owner |
Burlington |
Des Moines |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
2187 |
2024-04-29 08:30 |
Anonymous (not verified) |
94.188.207.226 |
Fran Stonework LLC |
Limited Liability Company |
1222 E Seneca Ave Apt 7, Des Moines, IA 50316 |
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. |
2024-04-29 |
Francisco Rodriguez Rios |
panchito941@icloud.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Francisco Rodriguez Rios |
panchito941@icloud.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2186 |
2024-04-28 11:12 |
Anonymous (not verified) |
94.188.205.168 |
John Martin |
Proprietorship |
1378 60th avenue Blue Grass Iowa |
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. |
2024-04-28 |
John D Martin |
martinflooring@netzero.com |
Blue Grass |
Muscatine |
Iowa |
John D Martin |
John D Martin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John D Martin |
martinflooring@netzero.com |
Owner |
Blue Grass |
Muscatine |
Iowa |
John D Martin |
John D Martin |
Signed |
2185 |
2024-04-26 16:46 |
Anonymous (not verified) |
94.188.205.166 |
Jerilyn Horn Kitchen and Bath Design Co. |
Proprietorship |
413 Jefferson St., Burlington, IA 52601 |
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. |
2024-04-26 |
Jerilyn Michelle Horn |
designsbyjerilyn@gmail.com |
Mt. Pleasant |
Henry |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jerilyn Michelle Horn |
designsbyjerilyn@gmail.com |
owner |
Mt. Pleasant |
Henry |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
2184 |
2024-04-26 15:03 |
Anonymous (not verified) |
94.188.205.166 |
Cory's Painting LLC |
Limited Liability Company |
Po Box 1161, Cedar Falls, Iowa 50613 |
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. |
2024-04-15 |
Joseph Abrahamson |
abrahamsonjd95@gmail.com |
Readlyn |
Bremer |
United States |
Colton Blue |
Kari Houle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cory Koger |
coryspainting@gmail.com |
Self |
Cedar Falls |
Blackhawk |
Iowa |
Colton Blue |
Kari Houle |
Signed |
2183 |
2024-04-26 14:49 |
Anonymous (not verified) |
94.188.205.168 |
Cory's Painting LLC |
Limited Liability Company |
Po Box 1161 |
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. |
2024-04-01 |
Jared Birkenholz |
jareddrewb@gmail.com |
CEDAR FALLS |
IA |
United States |
Colton Blue |
Kari Houle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cory Koger |
coryspainting@gmail.com |
Self |
CEDAR FALLS |
IA |
United States |
Colton Blue |
Kari Houle |
Signed |
2182 |
2024-04-25 19:37 |
Anonymous (not verified) |
94.188.205.174 |
Curtis Bunnell sub contractor |
Proprietorship |
907 s main st sigourney IA 52591 |
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. |
2024-04-23 |
CURTIS BUNNELL |
curt3551.cb@gmail.com |
Sigourney |
Keokuk |
IA |
Latisha Bunnell |
Wendy Yeo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Curtis bunnell |
curt3551.cb@gmail.com |
Same person |
Sigourney |
Keokuk |
IA |
Latisha bunnell |
Wendy Yeo |
Signed |
2181 |
2024-04-25 15:41 |
Anonymous (not verified) |
94.188.205.168 |
Ev's Ice Cream LLC |
Limited Liability Company |
2205 1/2 S Center St, Marshalltown, IA 50158-5960 |
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. |
2024-04-25 |
Kathryn Perry-Jenkins |
hawkeyesfan.22.kp@gmail.com |
Marshalltown |
Marshall |
IA |
Rebecca Houg |
Dakota Himes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kathryn Perry-Jenkins |
hawkeyesfan.22.kp@gmail.com |
Self |
Marshalltown |
Marshall |
IA |
Rebecca Houg |
Dakota Himes |
Signed |
2180 |
2024-04-25 14:19 |
Anonymous (not verified) |
94.188.205.169 |
Stems Flower Shop, LLC |
Limited Liability Company |
515 8th St SE |
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. |
2024-04-22 |
Stephanie Groom |
stephanie.groom@stemsiowa.com |
Altoona |
Polk |
Iowa |
Kelli Kerton |
Tyler Ingle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stephanie Groom |
stephanie.groom@stemsiowa.com |
Self - Business Owner |
Altoona |
Polk |
Iowa |
Kelli Kerton |
Tyler Ingle |
Signed |
2179 |
2024-04-25 10:58 |
Anonymous (not verified) |
94.188.205.177 |
Loonpa Landscaping LLC |
Limited Liability Partnership |
5309 Red Oak Ln Cedar Falls, IA 50613 |
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. |
2024-04-25 |
Brent Barloon |
Brent@barerootslawn.care |
WAterloo |
Black Hawk |
Iowa |
James White |
Kari White |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Daniel White |
danny@barerootslawn.care |
Owner |
Cedar Falls |
Black Hawk |
Iowa |
James White |
Kari White |
Signed |
2178 |
2024-04-25 10:56 |
Anonymous (not verified) |
94.188.205.176 |
Loonpa Landscaping LLC |
Limited Liability Partnership |
5309 Red Oak Ln Cedar Falls, IA 50613 |
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. |
2024-04-25 |
Daniel J White |
danny@barerootslawn.care |
Cedar Falls |
Black Hawk |
iowa |
Kari White |
James White |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Daniel J White |
danny@barerootslawn.care |
Owner |
Cedar Falls |
Black Hawk |
Iowa |
James White |
Kari White |
Signed |
2177 |
2024-04-24 13:50 |
Anonymous (not verified) |
94.188.205.175 |
Epic Tile and Bathroom Remodeling |
Proprietorship |
815 Isett Ave Wapello, IA 52653 |
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. |
2024-04-24 |
Bruce Conrad Briggs |
epictileiowa@gmail.com |
Wapello |
Louisa |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bruce Conrad Briggs |
epictileiowa@gmail.com |
owner |
Wapello |
Louisa |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
2176 |
2024-04-24 11:12 |
Anonymous (not verified) |
94.188.205.176 |
Schutters Pest Control Inc. |
Limited Liability Company |
109 2nd Ave, Suite #2, 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. |
2024-04-04 |
Billy Y Schutters |
schutterspestcontrol@gmail.com |
Bettendorf |
Iowa |
United States |
Aidan Sammon |
Kalissa Malin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Billy Y Schutters |
schutterspestcontrol@gmail.com |
Same Person |
Carbon Cliff |
Rock Island |
Illinois |
Aidan Sammon |
Kalissa Malin |
Signed |
2175 |
2024-04-24 09:14 |
Anonymous (not verified) |
94.188.207.229 |
John Sapp |
Proprietorship |
2120 South Main Street Burlington, IA52601 |
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. |
2024-04-23 |
John Curtis Sapp Jr. |
jbuddysapp@gmail.com |
Burlington |
Des Moines |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John C. Sapp Jr. |
jbuddysapp@gmail.com |
owner |
Burlington |
Des Moines |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
2174 |
2024-04-24 08:22 |
Anonymous (not verified) |
94.188.205.175 |
White's Floorcovering |
Proprietorship |
129 Hillcrest Dr. Biggsville, IL 61418 |
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. |
2024-04-22 |
Ron White |
hntwhite@frontiernet.net |
Biggsville |
Henderson |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ron White |
hntwhite@frontiernet.net |
owner |
Biggsville |
Henderson |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
2173 |
2024-04-23 14:19 |
Anonymous (not verified) |
94.188.205.166 |
Duer and Sons Remodeling, Inc |
Partnership |
1795 Se 82nd St, Runnells Iowa 50237 |
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. |
2024-04-23 |
John Duer |
John@duerandsonsremodeling.com |
Runnells |
Polk |
Iowa |
Travis Justice |
Jake VanGorp |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Duer |
John@duerandsonsremodeling.com |
Owner |
Runnells |
Polk |
Iowa |
Travis Justice |
Jake VanGorp |
Signed |
2172 |
2024-04-22 14:09 |
Anonymous (not verified) |
94.188.205.167 |
Melissa J Madison |
Proprietorship |
326 NE Olivewood Waukee, IA 50263 |
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. |
2024-04-22 |
Melissa Janelle Madison |
melissamadison01@gmail.com |
Waukee |
DALLAS |
IOWA |
Haley Sears |
Scott Leinen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melissa Madison |
melissamadison01@gmail.com |
myself |
Waukee |
Dallas |
Iowa |
Haley Sears |
Scott Leinen |
Signed |
2171 |
2024-04-22 14:09 |
Anonymous (not verified) |
94.188.205.176 |
Messer's concrete cutting |
Proprietorship |
714 Summer Street |
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. |
2024-04-22 |
Joe messer |
josephdmesser@gmail.com |
Burlington |
IA |
United States |
Joe messer |
Joe messer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joe messer |
josephdmesser@gmail.com |
Owner |
Burlington |
IA |
United States |
Joe messer |
Joe messer |
Signed |
2170 |
2024-04-22 10:11 |
Anonymous (not verified) |
94.188.207.224 |
Joy Ride Transport |
Limited Liability Company |
3105 SE Miehe Drive, Grimes, IA 50111 |
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. |
2024-04-22 |
Ted Cochran |
ted@ridejoyride.com |
Clive |
Dallas |
IA |
Lindsey Pace |
Carissa Gehrking |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ted Cochran |
ted@ridejoyride.com |
Self |
Clive |
Dallas |
IA |
Lindsey Pace |
Carissa Gehrking |
Signed |
2169 |
2024-04-22 09:49 |
Anonymous (not verified) |
94.188.205.166 |
Galatic Service LLC |
Proprietorship |
623 1st street silvis IL 61282 |
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. |
2024-04-22 |
Marcos Gonzales |
Marcosg300@yahoo.com |
Silvis |
Rock Island |
IL |
Jordan lyod |
Jordan Nisiewicz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas city |
Johnson |
MO |
Marcos Gonzales |
Jordan Lyod |
Signed |
2168 |
2024-04-22 08:18 |
Anonymous (not verified) |
94.188.207.228 |
Mattson's Floor Covering |
Proprietorship |
2073 Sandy 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. |
2024-04-22 |
Blaine Linn Mattson |
tmatzan99@yahoo.com |
Oquawka |
Henderson |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Blaine Mattson |
tmatzan22@yahoo.com |
owner |
Oquawka |
Henderson |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
2167 |
2024-04-21 22:01 |
Anonymous (not verified) |
94.188.205.177 |
The Duerson Corportaion |
Proprietorship |
601 1st Ave N, Altoona, IA 50009 |
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. |
2024-04-21 |
Nicholas John Myers |
myersnicholasj@gmail.com |
Norwalk |
IA |
United States |
Theresa Myers |
Bradyn Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas John Myers |
myersnicholasj@gmail.com |
Owner |
Norwalk |
IA |
United States |
Theresa Myers |
Bradyn Smith |
Signed |
2166 |
2024-04-20 13:38 |
Anonymous (not verified) |
94.188.205.175 |
Cedar Valley Seamless, LLC |
Limited Liability Company |
1184 215th St, Jesup, IA 50648 |
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. |
2024-04-20 |
Andrew Richard Trumbauer |
cedarvalleyseamlessllc@gmail.com |
Jesup |
Buchanan |
Iowa |
James William Masteller |
Andrew William Hamilton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andrew Richard Trumbauer |
cedarvalleyseamlessllc@gmail.com |
Owner/Operator |
Jesup |
Buchanan |
Iowa |
James William Masteller |
Andrew William Hamilton |
Signed |
2165 |
2024-04-19 14:05 |
Anonymous (not verified) |
94.188.207.225 |
Apex Striping LLC |
Limited Liability Company |
1325 Western Ave, cedar Falls, IA. 50613 |
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. |
2024-04-19 |
Chaz Ernest Torres |
admin@apexstripingia.com |
Cedar Falls |
Blackhawk |
Iowa |
Theresa Jo Torres |
Eloy James Torres |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chaz Ernest Torres |
admin@apexstripingia.com |
Self |
Cedar Falls |
Blackhawk |
Iowa |
Theresa Jo Torres |
Eloy James Torres |
Signed |
2164 |
2024-04-19 13:52 |
Anonymous (not verified) |
94.188.205.167 |
RKB Designs LLC |
Limited Liability Company |
4333 Cedar St, Davenport, IA 52806 |
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. |
2024-04-19 |
Ashley Rocca |
roccafive@gmail.com |
Davenport |
IA |
United States |
Nicholas Rocca |
Joni Long |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ashley Rocca |
roccafive@gmail.com |
Self |
Davenport |
IA |
United States |
Nicholas Rocca |
Joni Long |
Signed |
2163 |
2024-04-19 08:53 |
Anonymous (not verified) |
94.188.205.174 |
George Petree |
Proprietorship |
1219 N 7th St. Burlington, IA 52601 |
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. |
2024-04-19 |
George Harlan Petree |
g_petree@hotmail.com |
Burlington |
Des Moines |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
George Harlan Petree |
g_petree@hotmail.com |
owner |
Burlington |
Des Moines |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
2162 |
2024-04-18 19:25 |
Anonymous (not verified) |
94.188.205.177 |
Escobar Enterprises, LLC |
Limited Liability Company |
125 East Broad Street, Des Moines, Iowa 50315 |
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. |
2024-04-18 |
Jesse Escobar |
jesse@escobar-enterprises.com |
Des Moines |
Polk |
Iowa |
Rene Mauricio Martinez |
Jessa Caitlin Marfal |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jesse Escobar |
jesse@escobar-enterprises.com |
owner |
Des Moines |
Polk |
Iowa |
Rene Mauricio Martinez |
Jessa Caitlin Marfal |
Signed |
2161 |
2024-04-18 15:40 |
Anonymous (not verified) |
94.188.205.176 |
Thad A Holdefer |
Proprietorship |
313 Ruthella Drive West Burlington, IA 52655 |
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. |
2024-04-18 |
Thad A. Holdefer |
thadholdefer@yahoo.com |
West Burlington |
Des Moines |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Thad A Holdefer |
thadholdefer@yahoo.com |
owner |
West Burlington |
Des Moines |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
2160 |
2024-04-17 18:21 |
Anonymous (not verified) |
94.188.207.226 |
QC Remodeling LLC |
Limited Liability Company |
421 West Broadway, Ste 302 Council Bluffs, IA 51503 |
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. |
2024-04-17 |
Fernando Ibarra |
ibarra_fernando@hotmail.com |
Rock Island |
Rock Island |
Illinois |
Paula Barria |
Louis Valencia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Fernando Ibarra |
ibarra_fernando@hotmail.com |
Owner |
Rock Island |
Rock Island |
Illinois |
Paula Barria |
Louis Valencia |
Signed |
2159 |
2024-04-17 12:28 |
Anonymous (not verified) |
94.188.207.229 |
Mildred Lopez Camacho |
Proprietorship |
214 1st Ave SW Hampton, Iowa 50441 |
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. |
2024-04-17 |
Mildred Lopez Camacho |
morrison.hpd@gmail.com |
Hampton |
Franklin |
Iowa |
Ixia Anduce |
Jonathan Morales |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mildred Lopez Camacho |
morrison.hpd@gmail.com |
Self |
Hampton |
Franklin |
IOwa |
Ixia Anduce |
Jonathan Morales |
Signed |
2158 |
2024-04-17 11:47 |
Anonymous (not verified) |
94.188.207.228 |
Mildred Lopez |
Proprietorship |
214 1st Ave SW Hampton, Iowa 50441 |
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. |
2024-04-17 |
Mildred Lopez Camacho |
morrison.hpd@gmail.com |
Hampton |
Franklin |
Iowa |
Ixia Anduce |
Mark Morrison |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mildred Lopez |
morrison.hpd@gmail.com |
Self |
Hampton |
Franklin |
IOwa |
Ixia Anduce |
Mark Morrison |
Signed |
2157 |
2024-04-17 11:16 |
Anonymous (not verified) |
94.188.205.168 |
LAKESIDE DETAILING LLC |
Limited Liability Company |
249 EMERALD MEADOWS DR, ARNOLDS PARK, IA 51331 |
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. |
2024-04-17 |
DYLAN MCHUGH |
19DMCHUGH@GMAIL.COM |
ARNOLDS PARK |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
DYLAN MCHUGH |
19DMCHUGH@GMAIL.COM |
SELF |
ARNOLDS PARK |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
2156 |
2024-04-16 17:00 |
Anonymous (not verified) |
94.188.205.166 |
BONILLA STONE LLC |
Limited Liability Company |
3201 COLUMBIA ST DES MOINES, IA 50313 |
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. |
2024-04-16 |
JAIRO JAVIER BONILLA SERRANO |
jairobonilla509@gmail.com |
DES MOINES |
POLK |
IOWA |
ROCIO REYES |
JOSE HERNANDEZ |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JAIRO JAVIER BONILLA SERRANO |
jairobonilla509@gmail.com |
SAME |
DES MOINES |
POLK |
IOWA |
ROCIO REYES |
JOSE HERNANDEZ |
Signed |
2155 |
2024-04-16 08:13 |
Anonymous (not verified) |
94.188.207.225 |
Andrew M Riggins |
Proprietorship |
12905 N 1050th Road, Macomb, IL 61455 |
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. |
2022-08-02 |
Andrew M Riggins |
kellylanz1967@gmail.com |
Macomb |
IL |
United States |
Barb Coker |
Scott Caspall |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andrew M Riggins |
kellylanz1967@gmail.com |
Self |
Macomb |
IL |
United States |
Barb Coker |
Scott Caspall |
Signed |
2154 |
2024-04-16 08:05 |
Anonymous (not verified) |
94.188.207.226 |
Lanz Pork Inc |
Proprietorship |
12905 N 1050th Road, Macomb, IL 61455 |
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. |
2022-08-02 |
Andrew M Riggins |
kellylanz1967@gmail.com |
Macomb |
IL |
United States |
Barb Coker |
Scott Caspall |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andrew M Riggins |
kellylanz1967@gmail.com |
Self |
Macomb |
IL |
United States |
Barb Coker |
Scott Caspall |
Signed |
2153 |
2024-04-15 21:59 |
Anonymous (not verified) |
94.188.205.167 |
Ethan M Hoffman |
Proprietorship |
1442 N. County RD 800, Hamilton, IL 62341 |
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. |
2022-09-07 |
Ethan M Hoffman |
kellylanz1967@gmail.com |
Hamilton |
IL |
United States |
Gay Hoffman |
Debra Kelley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ethan M Hoffman |
kellylanz1967@gmail.com |
Self |
Hamilton |
IL |
United States |
Gay Hoffman |
Debra Kelley |
Signed |
2152 |
2024-04-15 17:23 |
Anonymous (not verified) |
94.188.207.230 |
ServiceMaster by Harris |
Proprietorship |
432 Locust Street Waterloo, IA 50701 |
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. |
2024-04-15 |
Joel Harris |
joel.harris@forbin.net |
Waterloo |
IA |
IA |
None |
None |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joel Harris |
joel.harris@forbin.net |
Owner |
Waterloo |
IA |
IA |
None |
None |
Signed |
2151 |
2024-04-15 14:42 |
Anonymous (not verified) |
94.188.207.227 |
Jose Acuna |
Proprietorship |
1015 East Main Street, Belmond, IA 50421, US |
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. |
2024-04-15 |
Jose Acuna |
Joseacuna@gmail.com |
Belmond, IA |
Wright |
Iowa |
Jordan Loyd |
Jordan Nisiewicz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Johnson |
Missouri |
Jordan Loyd |
Cody Dunbar |
Signed |
2150 |
2024-04-15 12:07 |
Anonymous (not verified) |
94.188.205.177 |
Todd E Holsteen |
Proprietorship |
16015 Hwy 99, Burlington, IA 52601 |
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. |
2022-11-28 |
Todd E Holsteen |
kellylanz1967@gmail.com |
Burlington |
IL |
United States |
David Steele |
Kari Holsteen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Todd E Holsteen |
kellylanz1967@gmail.com |
Self |
Burlington |
IA |
United States |
David Steele |
Kari Holsteen |
Signed |
2149 |
2024-04-15 11:20 |
Anonymous (not verified) |
94.188.207.224 |
Grady Yeggy |
Proprietorship |
211 3rd 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. |
2022-12-11 |
Grady S Yeggy |
kellylanz1967@gmail.com |
Riverside |
IA |
United States |
Amanda Yeggy |
Leah Evans |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Grady S Yeggy |
kellylanz1967@gmail.com |
Self |
Riverside |
IA |
United States |
Amanda Yeggy |
Leah Yeggy |
Signed |
2148 |
2024-04-15 11:15 |
Anonymous (not verified) |
94.188.207.224 |
Derek Fetzer |
Proprietorship |
360 250th St, West Branch, IA 52358 |
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. |
2022-12-17 |
Dere W Fetzer |
kellylanz1967@gmail.com |
West Branch |
IA |
United States |
Maribelle Lund |
Carl Lund |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derek Fetzer |
kellylanz1967@gmail.com |
Self |
West Branch |
IA |
United States |
Maribelle Lund |
Carl Lund |
Signed |
2147 |
2024-04-12 11:52 |
Anonymous (not verified) |
94.188.205.166 |
Tri County Enterprise |
Partnership |
5527 Crane Lane 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. |
2024-04-12 |
Ken McGraw |
kenmcgraw1974@gmail.com |
Center Point |
IA |
United States |
bob nissen |
Jenny Vaske |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Ashlock |
brian@tricounty-iowa.com |
General Manager |
Shellsburg |
IA |
United States |
bob Nissen |
Jenny Vaske |
Signed |
2146 |
2024-04-12 11:42 |
Anonymous (not verified) |
94.188.207.226 |
Ken McGraw |
Proprietorship |
162 Green St Center Point IA 52213 |
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. |
2024-04-12 |
Ken Mcgraw |
kenmcgraw1974@gmail.com |
Center Point |
Linn |
Iowa |
Jenny Vaske |
Bob Nissen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Ashlock |
brian@tricounty-iowa.com |
General Manager |
Cedar Rapids |
Linn |
Iowa |
Bob Nissen |
Jenny Vaske |
Signed |
2145 |
2024-04-11 12:27 |
Anonymous (not verified) |
94.188.205.177 |
Grinnell Web Services LLC |
Limited Liability Company |
1902 Spring St, Grinnell IA 50112 |
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. |
2024-04-11 |
Richard Ethington |
RDE326@rrmse.com |
Grinnell |
Poweshiek |
Iowa |
Lori Stratton |
Lisa Folkmann |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Richard Ethington |
rde326@rrmse.com |
self |
Grinnell |
poweshiek |
iowa |
lori stratton |
lisa folkmann |
Signed |
2144 |
2024-04-10 14:23 |
Anonymous (not verified) |
94.188.205.176 |
Heaven Sent PC LLC |
Limited Liability Company |
604 Allamakee 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. |
2024-04-10 |
Justin PIggott |
heavensentpetcremation@gmail.com |
Waukon |
Allamakaee |
IA |
Jane M Regan |
Nancy Bechtel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Piggott |
heavensentpetcremation@gmail.com |
LLC Member |
Waukon |
Allamakee |
IA |
Jane M Regan |
Nancy Bechtel |
Signed |
2143 |
2024-04-09 13:05 |
Anonymous (not verified) |
94.188.207.230 |
CO2 Refrigeration Systems (Iowa) LLC |
Limited Liability Company |
315 E 5th St Ste 202, Waterloo, IA 50703 |
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. |
2024-04-09 |
Zachary Heintz Laws |
zach.laws@co2refsystems.com |
Marshalltown |
Marshall |
Iowa |
Robert E Shomo |
Steven M Madsen |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Zachary Heintz Laws |
zach.laws@co2refsystems.com |
Self |
Marshalltown |
Marshall |
Iowa |
Robert E Shomo |
Steven M Madsen |
Signed |
2142 |
2024-04-09 09:39 |
Anonymous (not verified) |
94.188.205.167 |
Bart Fuller & james Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln Street Ruthven, IA 51358 |
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. |
2024-04-09 |
James Fuller |
goffins@ruthventel.com |
Ruthven |
Pal Alto |
Iowa |
Kathryn Kelley |
Janice Henningsen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
Palo Alto |
Iowa |
Kathryn Kelley |
Janice Henningsen |
Signed |
2141 |
2024-04-09 09:34 |
Anonymous (not verified) |
94.188.205.177 |
Bart Fuller & James Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln Street Ruthven, IA 51358 |
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. |
2024-04-09 |
James Fuller |
goffins@ruthventel.com |
Ruthven |
Palo Alto |
Iowa |
Kathryn Kelley |
Janice Henningsen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
Palo Alto |
Iowa |
Kathryn Kelley |
Janice Henningsen |
Signed |
2140 |
2024-04-09 09:28 |
Anonymous (not verified) |
94.188.205.175 |
Bart Fuller& James Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln Street Ruthven, IA 51358 |
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. |
2024-04-09 |
Bart Fuller |
goffins@ruthventel.com |
Ruthven |
Palo Alto |
Iowa |
Kathryn Kelley |
Janice Henningsen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bart Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
PAlo Alto |
Iowa |
Kathryn Kelley |
Janice Henningsen |
Signed |
2139 |
2024-04-08 10:35 |
Anonymous (not verified) |
94.188.205.168 |
Professional Hardwood Floors LLC |
Limited Liability Company |
14858 118th Ave, Indianola, IA 50125 |
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. |
2024-04-08 |
Ivan Pilat |
professionalfloors@ymail.com |
Indianola |
Warren |
iowa |
Mark Kapysten |
Vladmir Orbedan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ivan Pilat |
professionalfloors@ymail.com |
Self |
Indianola |
Warren |
Iowa |
Mark Kapysten |
Vladmir Orbedan |
Signed |
2138 |
2024-04-05 12:30 |
Anonymous (not verified) |
94.188.205.167 |
Joseph L Neighbors dba J L N Trucking |
Proprietorship |
5466 18th Ave Mount Auburn IA 52313 |
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. |
2024-04-05 |
Joseph L Neighbors |
robynne@cmbrown.net |
Mount Auburn |
Benton |
Iowa |
Sarah Svehla |
Angela Vangennip |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robynne Dawn Duvall |
robynne@cmbrown.net |
insurance agent |
Perryville |
Missouri |
Missouri |
Sarah Svehla |
Angela Vangennip |
Signed |
2137 |
2024-04-05 10:28 |
Anonymous (not verified) |
94.188.207.227 |
Innovationsgenc@gmail.com |
Limited Liability Company |
1134 20th Avenue |
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. |
2024-04-05 |
Juan carlos Soto Deanda |
charlye2512penelope@gmail.com |
East Moline |
IL |
United States |
Deja Rivers |
Eric Schwab |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Juan carlos Soto Deanda |
charlye2512penelope@gmail.com |
Owner |
East Moline |
IL |
United States |
Deja Rivers |
Eric Schwab |
Signed |
2136 |
2024-04-04 16:08 |
Anonymous (not verified) |
94.188.205.169 |
Elite Construction & Masonry LLC |
Limited Liability Company |
3309 Wright St Des Moines IA 50316 |
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. |
2024-04-04 |
Manuel Mejia |
eliteconstructionmasonryllc@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Manuel Mejia |
eliteconstructionmasonryllc@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2135 |
2024-04-04 11:02 |
Anonymous (not verified) |
94.188.207.227 |
Jonathan Warner |
Proprietorship |
420 16th Avenue, East Moline, IL 61244, US |
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. |
2024-04-04 |
Jonathan Warner |
bsguttersllc@gmail.com |
East Moline, IL |
Moline |
Illinois |
Jordan Nisiewicz |
Cody Dunbar |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Johnson |
MO |
Jordan Loyd |
Cody Dunbar |
Signed |
2134 |
2024-04-04 08:10 |
Anonymous (not verified) |
94.188.205.169 |
TERRA CONSTRUCTION LLC |
Limited Liability Company |
621 Oak Park Ave Des Moines, IA 50313 |
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. |
2024-04-04 |
Bryce Shabazz |
block.radio@yahoo.com |
Des Moines |
Polk |
Iowa |
Megan Donigan |
George Hana |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jessica L Heller |
Jessica.heller@adp.com |
Insurance Agent |
Allentown |
Lehigh |
PA |
Megan Donigan |
George Hana |
Signed |
2133 |
2024-04-03 19:58 |
Anonymous (not verified) |
94.188.207.228 |
Soto Stone LLC |
Limited Liability Company |
1071 mansfield Dr waukee iowa 50263 |
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. |
2024-04-03 |
Yesser Lenin Juarez Soto |
sotostonellc95@gmail.com |
waukee |
Dallas |
Iowa |
Ashley Marie Francisco |
Vincent Alexander Flores |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Yesser Lenin Juarez Soto |
sotostonellc95@gmail.com |
self |
waukee |
Dallas |
Iowa |
Ashley Marie Francisco |
Vincent Alexander Flores |
Signed |
2132 |
2024-04-03 19:49 |
Anonymous (not verified) |
94.188.205.166 |
Soto Stone LLC |
Limited Liability Partnership |
1071 mansfield Dr waukee iowa 50263 |
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. |
2024-04-03 |
Yesser Lenin Juarez Soto |
sotostonellc95@gmail.com |
waukee |
Dallas |
Iowa |
Ashley Marie Francisco |
Vincent Alexander Flores |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Yesser Lenin Juarez Soto |
sotostonellc95@gmail.com |
self |
waukee |
Dallas |
Iowa |
Ashley Marie Francisco |
Vincent Alexander Flores |
Signed |
2131 |
2024-04-02 10:28 |
Anonymous (not verified) |
94.188.205.168 |
Driskell Spray, LLC |
Limited Liability Company |
1279 300th Ave Sidney, IA 51652 |
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. |
2024-03-22 |
Jamie Driskell |
driskell216@gmail.com |
Sidney |
Fremont |
Iowa |
Melinda Goy |
Rhett Goy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jamie Driskell |
driskell216@gmail.com |
owner |
Sidney |
Fremont |
Iowa |
Melinda Goy |
Rhett Goy |
Signed |
2130 |
2024-04-02 09:11 |
Anonymous (not verified) |
94.188.207.229 |
Caliz Stone Services LLC |
Limited Liability Company |
1715 E 21st St, 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. |
2024-04-02 |
Marvin Lopez |
marvincaliz843@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marvin Lopez |
marvincaliz843@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2129 |
2024-04-01 14:16 |
Anonymous (not verified) |
94.188.207.227 |
Des Moines Construction LLC |
Limited Liability Company |
6615 SE 3rd St Des Moines IA 50315 |
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. |
2024-04-01 |
Rodrigo Valdes |
desmoinesconstructionllc@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rodrigo Valdes |
desmoinesconstructionllc@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2128 |
2024-03-29 09:52 |
Anonymous (not verified) |
94.188.207.228 |
Mason Quality and Sons LLC |
Proprietorship |
18921 Willow St Omaha Ne 68136 |
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. |
2024-03-29 |
Joel Castillo |
drake.centurion@gmail.com |
Omaha |
Douglas |
Nebraska |
Drake Rapaich |
Sunita Rapaich |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joel Castillo |
drake.centurion@gmail.com |
self |
Omaha |
Douglas |
Nebraska |
Drake Rapaich |
Sunita Rapaich |
Signed |
2127 |
2024-03-29 09:50 |
Anonymous (not verified) |
94.188.205.177 |
Peterson Home Improvement, LLc |
Limited Liability Company |
31451 510th Street Russ |
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. |
2024-03-29 |
Paul M Peterson |
petersonhomeimprovementllc@gmail.com |
Russell |
Iowa |
Iowa |
Peggy Jo Peterson |
Matthew Peterson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Peggy Peterson |
petersonhomeimprovementllc@gmail.com |
Husband |
Russell |
Lucas |
Iowa |
Paul M Peterson |
Matthew Peterson |
Signed |
2126 |
2024-03-29 09:35 |
Anonymous (not verified) |
94.188.207.227 |
MPO Masonry |
Proprietorship |
5027 s 20th at apt 12 Omaha ne 68107 |
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. |
2024-03-29 |
Mauricio Ortega |
pallaresmauricio72@gmail.com |
Omaha |
Douglas |
Nebraska |
Drake Rapaich |
Sunita Rapaich |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mauricio Ortega |
pallaresmauricio72@gmail.com |
Self |
Omaha |
Douglas |
Nebraska |
Drake Rapaich |
Sunita Rapaich |
Signed |
2125 |
2024-03-28 23:17 |
Anonymous (not verified) |
94.188.207.223 |
MB Lawn Care |
Limited Liability Company |
7018 Deerview Dr Urbandale IA 50322 |
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. |
2024-03-28 |
Mirnes Becirovic |
Mirnes2012@me.com |
Urbandale |
Polk |
Iowa |
Mirnes Becirovic |
Mirnes Becirovic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mirnes Becirovic |
mirnes2012@me.com |
Owner |
Urbandale |
Polk |
Iowa |
Mirnes Becirovic |
Mirnes Becirovic |
Signed |
2124 |
2024-03-28 13:47 |
Anonymous (not verified) |
94.188.207.225 |
Gudiel Construction & Masonry LLC |
Limited Liability Company |
303 Lacona Ave Des Moines Iowa 50315 |
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. |
2024-03-28 |
Santiago Gudiel Lopez |
gudielsantiago972@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Santiago Gudiel Lpez |
gudielsantiago972@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2123 |
2024-03-28 10:42 |
Anonymous (not verified) |
94.188.207.229 |
J&J Masonry |
Proprietorship |
2519 Poppleton Ave |
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. |
2024-03-28 |
Jose Marroquin |
drakkarhr7@gmail.com |
Omaha |
Douglas |
Nebraska |
Drake Rapaich |
Sunita Rapaich |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Marroquin |
drakkarhr7@gmail.com |
Self |
Omaha |
Douglas |
Nebraska |
Drake Rapaich |
Sunita Rapaich |
Signed |
2122 |
2024-03-28 10:15 |
Anonymous (not verified) |
94.188.205.169 |
Stone Villalobos LLC |
Limited Liability Company |
4231 Morton 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. |
2024-03-28 |
Josue Villalobos |
villalobosjosue2016@gmail.com |
Des Moines |
Polk |
Iowa |
Edgar Palomares |
Fabiola Palomares Recendiz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josue Villalobos |
villalobosjosue2016@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Edgar Palomares |
Fabiola Palomares Recendiz |
Signed |
2121 |
2024-03-28 00:05 |
Anonymous (not verified) |
94.188.205.176 |
James bunting |
Limited Liability Company |
6213 ridgewood meadows LN 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. |
2024-03-28 |
James bunting |
jbflooringtile@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Codee Marie |
Matt reynolds |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James bunting |
jbflooringtile@gmail.com |
Myself |
Cedar Rapids |
Linn |
Iowa |
Codee Marie |
Matt reynolds |
Signed |
2120 |
2024-03-27 15:31 |
Anonymous (not verified) |
94.188.205.169 |
Dustin pleshe |
Proprietorship |
6855 woodland ave unit 505 |
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. |
2024-03-27 |
Dustin Pleshe |
dustinjpleshe@gmail.com |
WEST DES MOINES |
Iowa |
United States |
Kasey Cunningham |
Kathy Cunningham |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Pleshe |
dustinjpleshe@gmail.com |
He is me |
WEST DES MOINES |
Iowa |
United States |
Kasey cunningham |
Kathy cunningham |
Signed |
2119 |
2024-03-27 14:27 |
Anonymous (not verified) |
94.188.205.169 |
juan garcia |
Proprietorship |
3359 Patrick Ave |
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. |
2024-03-27 |
Juan Garcia |
garcia.stone2022@gmail.com |
omaha |
Douglas |
Nebraska |
Ashlee Virves |
Reyna Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Juan Garcia |
garcia.stone2022@gmail.com |
Self |
Omaha |
Douglas |
Nebraska |
Ashlee Virves |
Reyna Garcia |
Signed |