106 |
2020-03-31 10:42 |
Anonymous (not verified) |
209.152.77.101 |
Bart Fuller & James Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln ST., 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. |
2020-03-31 |
Bart Fuller |
goffins@ruthventel.com |
Ruthven |
Palo Alto |
Iowa |
Janice Henningsen |
Louise Helmke |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bart Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
Palo Alto |
Iowa |
Janice Henningsen |
Louise Helmke |
Signed |
107 |
2020-03-31 10:47 |
Anonymous (not verified) |
209.152.77.101 |
Bart Fuller & James Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln ST., 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. |
2020-03-31 |
James Fuller |
goffins@ruthventel.com |
Ruthven |
Palo Alto |
Iowa |
Janice Henningsen |
Louise Helmke |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
Palo Alto |
Iowa |
Janice Henningsen |
Louise Helmke |
Signed |
108 |
2020-04-01 16:50 |
Anonymous (not verified) |
206.72.23.71 |
Heartland Renovations, LLC |
Limited Liability Company |
50253 290th Street, Kelley, IA 50134 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-01 |
Troy Van Maaren |
almostanything2@gmail.com |
Kelley |
Iowa |
United States |
Tammy J Reid |
Todd L Greenslit |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Troy Van Maaren |
almostanything2@gmail.com |
Member |
Kelley |
Story |
Iowa |
Tammy J Reid |
Todd L Greenslit |
Signed |
109 |
2020-04-03 12:42 |
Anonymous (not verified) |
174.219.131.25 |
Upright Construction |
Limited Liability Company |
2514 S norton 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. |
2020-04-03 |
Maurice Williams |
uprightway@mail.com |
Sioux Falls |
Minihaha |
SD |
Ashley Williams |
Chris Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maurice Williams |
uprightway@mail.com |
Owner |
Sioux Falls |
Minihaha |
SD |
Ashley Williams |
Chris Johnson |
Signed |
110 |
2020-04-06 14:13 |
Anonymous (not verified) |
99.203.98.177 |
Stifel seasonal services |
Limited Liability Company |
935 4th street waukee |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-06 |
Dalton Stifel |
daltonstifel@icloud.com |
waukee |
Dallas |
IA |
Bryant ternes |
Tammy stifel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dalton Stifel |
daltonstifel@icloud.com |
Owner |
waukee |
Dallas |
IA |
Bryant Ternes |
Tammy Stifel |
Signed |
111 |
2020-04-06 16:04 |
Anonymous (not verified) |
209.152.124.33 |
SM Tile Design LLC |
Limited Liability Company |
670 Daybreak Drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-06 |
Samir Mulalic |
Smtiledesign@gmail.com |
WAUKEE |
Dallas |
Iowa |
Shawn Stanley |
Saneta Dzankovic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Samir Mulalic |
Smtiledesign@gmail.com |
Same |
WAUKEE |
Dallas |
Iowa |
Shawn Stanley |
Saneta Dzankovic |
Signed |
112 |
2020-04-07 12:16 |
Anonymous (not verified) |
173.27.33.108 |
Josh Alley Siding |
Proprietorship |
205 N Oak St. Davis City, IA 50065 |
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. |
2018-04-10 |
Joshua H. Alley |
alley.josh@yahoo.com |
Davis City |
Decatur |
Iowa |
Joe Fitzgerald |
Steve Young |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Alley Siding |
alley.josh@yahoo.com |
Owner |
Davis City |
Decatur |
Iowa |
Joe Fitzgerald |
Steve Young |
Signed |
114 |
2020-04-08 10:51 |
Anonymous (not verified) |
167.142.107.216 |
1959 |
Proprietorship |
601 Country Club Rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-23 |
Timothy Alan Pottebaum |
tpottebaum@nethtc.net |
SHELDON |
O'Brien |
Iowa |
Jill Boerta |
Kris Schoo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy Alan Pottebaum |
tpottebaum@nethtc.net |
owner |
SHELDON |
O'brien |
Iowa |
Jill Boerta |
Kris Schoo |
Signed |
115 |
2020-04-09 11:42 |
Anonymous (not verified) |
67.60.46.104 |
D&H Plumbing, L.L.C |
Limited Liability Company |
44214 260th St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-05 |
Delwayne Merrill Abbott |
del_abbott@yahoo.com |
Kingsley |
Plymouth |
Iowa |
Doug Alan Gerdes |
Nick William Lahrs |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Delwayne Merrill Abbott |
brettherbold@gmail.com |
Owner |
Kingsley |
Plymouth |
Iowa |
Doug Alan Gerdes |
Nick William Lahrs |
Signed |
116 |
2020-04-09 11:45 |
Anonymous (not verified) |
67.60.46.104 |
D&H Plumbing, L.L.C |
Limited Liability Company |
44214 260th St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-05 |
Brett Alan Herbold |
brettherbold@gmail.com |
Remsen |
Plymouth |
Iowa |
Doug Alan Gerdes |
Nick Willam Lahrs |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Delwayne Merrill Abbott |
brettherbold@gmail.com |
Owner |
Kinglsey |
Plymouth |
Iowa |
Doug Alan Gerdes |
Nick William Lahrs |
Signed |
117 |
2020-04-11 09:08 |
Anonymous (not verified) |
72.255.83.134 |
MIDWEST AG SOLUTIONS, LLC |
Limited Liability Company |
4949 PLEASANT ST, STE 204, WEST DES MOINES, IA 50266 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-11 |
DALE A EASTMAN |
dale@emdsm.com |
Waukee |
Dallas |
IA |
Gary Marshall |
Brittain Bachus |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
DALE A EASTMAN |
dale@emdsm.com |
same |
WAUKEE |
DALLAS |
IA |
GARY MARSHALL |
BRITTAIN BACHUS |
Signed |
118 |
2020-04-13 11:48 |
Anonymous (not verified) |
173.26.152.222 |
Society of St. Vincent de Paul, District Council of Waterloo Iowa,Inc |
Limited Liability Company |
320 Broadway St PO Box 2727 Waterloo IA 50704 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-14 |
Joseph D. Sobczyk |
joczyk@aol.com |
Cedar Falls |
Black Hawk |
Iowa |
George W. Karnick |
Glynis R. Worthington |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joseph D. Sobczyk |
joczyk@aol.com |
self |
Cedar Falls |
Black Hawk |
Iowa |
George W. Karnick |
Glynis R. Worthington |
Signed |
119 |
2020-04-14 14:38 |
Anonymous (not verified) |
66.188.136.150 |
Matthew Popejoy |
Proprietorship |
7897 21st Ave., Blaristown, IA 52209 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-14 |
Matthew Popejoy |
popejoymatthew@gmail.com |
Blairstown |
Benton |
IA |
Russell Masartis |
Cody McClain |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dan Oberfoell |
doberfoell@tricorinsurance.com |
Agent |
Blairstown |
Benton |
IA |
Russell Masartis |
Cody McClain |
Signed |
120 |
2020-04-14 14:58 |
Anonymous (not verified) |
66.188.136.150 |
Donald Hesseling |
Proprietorship |
3200 East Shaulis Rd., Waterloo, IA 50702 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-14 |
Donald Hesseling |
donkd0wgb@outlook.com |
Waterloo |
Blackhawk County |
IA |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dan Oberfoell |
doberfoell@tricorinsurance.com |
Agent |
Waterloo |
Blackhawk County |
IA |
Russell Masartis |
Nancy Wortley |
Signed |
121 |
2020-04-14 15:11 |
Anonymous (not verified) |
173.31.176.75 |
Society of St. Vincent de Paul, District council of Waterloo Iowa,Inc |
Limited Liability Company |
320 Broadway St PO Box 2727 Waterloo IA 50704 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-14 |
Michele E Collison |
darmstad48@aol.com |
Denver |
Bremer |
Iowa |
George W. Karnick |
Glynis R. Worthington |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joseph D. Sobczyk |
joczyk@aol.com |
Secretary of the St. Vincent de Paul District Council of Waterloo, Iowa, Inc. |
Denver |
Bremer |
Iowa |
George W. Karnick |
Glynis R. Worthington |
Signed |
122 |
2020-04-15 18:10 |
Anonymous (not verified) |
136.37.174.39 |
Merge Midwest Engineering, LLC |
Limited Liability Company |
2668 W. Catalpa Street, Olathe, KS 66061 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-15 |
Janelle Marie Clayton |
jclayton@mergemidwest.com |
Olathe |
Johnson |
Kansas |
David Jahner |
Patrick McCartney |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Janelle Marie Clayton |
jclayton@mergemidwest.com |
Self |
Olathe |
Johnson |
Kansas |
David Jahner |
Patrick McCartney |
Signed |
123 |
2020-04-16 08:33 |
Anonymous (not verified) |
159.242.36.129 |
Paul Brown |
Proprietorship |
5 Cedar Ridge CT, Ventura, IA 50482-8992 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-16 |
Paul Brown |
cedars4@cltel.net |
Ventura |
Cerro Gordo |
IA |
Tom Stephany |
Amanda Korenberg |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paul Brown |
cedars4@cltel.net |
self |
Ventura |
Cerro Gordo |
IA |
Tom Stephany |
Amanda Korenberg |
Signed |
124 |
2020-04-16 12:07 |
Anonymous (not verified) |
96.3.180.122 |
Gold Rush, LLC |
Limited Liability Company |
1395 130TH ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-16 |
Jay Christopher Morrow |
jcmorrow2@hotmail.com |
WAYLAND |
Henry |
IAUS |
chad mitchell |
Jonathan Mitchell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gold Rush, LLC |
jcmorrow2@gmail.com |
Self |
WAYLAND |
Henry |
IAUS |
chad mitchell |
Jonathan Mitchell |
Signed |
125 |
2020-04-20 19:01 |
Anonymous (not verified) |
67.22.196.182 |
Driven School of Driving |
Limited Liability Company |
451 E 1st ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-20 |
Justin J. Franken |
drivenschoolofdriving@gmail.com |
Sioux Center |
Sioux |
IA |
Robyn Franken |
Gracyn Franken |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Franken |
drivenschoolofdriving@gmail.com |
Me |
Sioux Center |
Sioux |
IA |
Robyn Franken |
Gracyn Franken |
Signed |
126 |
2020-04-21 21:19 |
Anonymous (not verified) |
69.76.135.87 |
Merge Midwest Engineering, LLC |
Limited Liability Company |
2668 W. Catalpa 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. |
2020-04-21 |
Mark Daniel Stuempel |
mstuempel@mergemidwest.com |
Kansas City |
Wyandotte |
KANSAS |
Anna Langer |
Donna Stuempel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Janelle Clayton |
jclayton@mergemidwest.com |
LLC Member |
Olathe |
Johnson |
KS |
Anna Langer |
Donna Stuempel |
Signed |
127 |
2020-04-24 09:18 |
Anonymous (not verified) |
63.152.82.5 |
TD Auto Services LLC |
Limited Liability Company |
451 W Parker St 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. |
(1) I am not electing the employers’ liability coverage. |
2020-01-27 |
Dakoda Sellers |
dakoda.d.sellers@gmail.com |
Waverly |
Bremer |
IA |
Jennie Roster |
Dustin Roster |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dakoda D Sellers |
dakoda.d.sellers@gmail.com |
Owner |
Waverly |
Bremer |
IA |
Jennie Roster |
Dustin Roster |
Signed |
128 |
2020-04-24 14:14 |
Anonymous (not verified) |
173.21.123.73 |
JLC Finish Trim Carpenter inc |
Proprietorship |
2620 61st st des moines iowa 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. |
2020-04-24 |
aura cordova mendoza |
isabel_menro81@yahoo.com |
des moines |
polk |
iowa |
emily segura |
roslyn duenas |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Mendoza |
jlctrimcarpenterinc@gmail.com |
employer |
des moines |
polk |
iowa |
emily segura |
roslyn duenas |
Signed |
129 |
2020-04-24 15:28 |
Anonymous (not verified) |
173.28.28.57 |
Michael Jansen |
Proprietorship |
108 6th Street, Parkersburg, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-10 |
Michael G Jansen |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael G Jansen |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
130 |
2020-04-27 10:36 |
Anonymous (not verified) |
66.188.136.150 |
David Roberts |
Proprietorship |
2600 Butterfield, PO Box 3251 Dubuque, IA 52004 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-24 |
David Roberts |
buman6578@gmail.com |
Dubuque |
Dubuque |
IA |
Russell Masartis |
Angie Olds |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Roberts |
kschumacher@tricorinsurance.com |
Owner Operator is Employer |
Dubuque |
Dubuque |
IA |
Russell Masartis |
Angie Olds |
Signed |
131 |
2020-04-27 15:01 |
Anonymous (not verified) |
66.188.136.150 |
Hashem Shawki |
Proprietorship |
8906 Newton Ave. S |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-27 |
Hashem Shawki |
kschumacher@tricorinsurance.com |
Bloomington |
Hennepin |
MN |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Hasham Shawki |
kschumacher@tricorinsurance.com |
Same person |
Bloomington |
Hennepin |
MN |
Russell Masartis |
Nancy Wortley |
Signed |
132 |
2020-04-27 17:26 |
Anonymous (not verified) |
73.94.97.93 |
Kota Construction |
Limited Liability Company |
52 SE Pembrooke Ln |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-27 |
Dakota Beaulieu |
cody.b@buildwithkota.com |
Waukee |
IA |
United States |
Kyli Torkelson |
Koray Furrow |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dakota Beaulieu |
cody.b@buildwithkota.com |
Self |
Waukee |
Dallas |
Iowa |
Kyli Torkelson |
Koray Furrow |
Signed |
133 |
2020-04-27 21:56 |
Anonymous (not verified) |
67.55.230.152 |
Hawkeye Carpentry LLC |
Limited Liability Company |
665 Penn Ridge Drive North Liberty, IA 52317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-27 |
Travis Jaquay |
tjaquay@hotmail.com |
North Liberty |
Johnson |
Iowa |
Amber Butera |
Matt Butera |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Compass Commercial Services |
Bshanahan@compass-built.com |
subcontractor |
Hiawatha |
Linn |
Iowa |
Amber Butera |
Matt Butera |
Signed |
134 |
2020-04-28 08:15 |
Anonymous (not verified) |
66.188.136.150 |
Lowell Fenton |
Proprietorship |
404 1/2 W Main St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-27 |
Lowell Fenton |
fentonlowell@gmail.com |
Decorah |
Winneshiek |
IA |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lowell Fenton |
kschumacher@tricorinsurance.com |
Same person |
Decorah |
Winneshiek |
IA |
Russell Masartis |
Shuree Behr |
Signed |
135 |
2020-04-28 10:04 |
Anonymous (not verified) |
74.84.101.138 |
W.A.D.E., Inc. DBA Decorah Cleaners |
Proprietorship |
504 Heivly Street Decorah, IA 52101 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-23 |
Darrin Walter |
chelsea.whalen@upperiowains.com |
Decorah |
Winneshiek |
IA |
Robin C Schultz |
Chelsea Whalen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Darrin Walter |
chelsea.whalen@upperiowains.com |
Owner |
Decorah |
Winneshiek |
IA |
Robin C Schultz |
Chelsea Whalen |
Signed |
136 |
2020-04-28 10:06 |
Anonymous (not verified) |
74.84.101.138 |
W. A. D. E., Inc. DBA Decorah Cleaners |
Proprietorship |
504 Heivly Street Decorah, IA 52101 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-23 |
Wanda Walter |
chelsea.whalen@upperiowains.com |
Decorah |
Winneshiek |
IA |
Robin C Schultz |
Chelsea Whalen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wanda Walter |
chelsea.whalen@upperiowains.com |
Owner |
Decorah |
Winneshiek |
IA |
Robin C Schultz |
Chelsea Whalen |
Signed |
137 |
2020-04-28 10:08 |
Anonymous (not verified) |
74.84.101.138 |
Nisse Preschool & Kids Place |
Partnership |
311 College Drive Decorah, IA 52101 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-26 |
Megan Sherman |
chelsea.whalen@upperiowains.com |
Decorah |
Winneshiek |
IA |
Michelle Ostern |
Robin C Schultz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Megan Sherman |
chelsea.whalen@upperiowains.com |
President |
Decorah |
Winneshiek |
IA |
Michelle Ostern |
Robin C Schultz |
Signed |
138 |
2020-04-28 10:10 |
Anonymous (not verified) |
74.84.101.138 |
Nisse Preschool & Kids Place |
Partnership |
311 College Drive Decorah, IA 52101 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-26 |
Tasha Sibley |
chelsea.whalen@upperiowains.com |
Decorah |
Winneshiek |
IA |
Michelle Ostern |
Robin C Schultz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tasha Sibley |
chelsea.whalen@upperiowains.com |
Secretary |
Decorah |
Winneshiek |
IA |
Michelle Ostern |
Robin C Schultz |
Signed |
139 |
2020-04-28 10:11 |
Anonymous (not verified) |
74.84.101.138 |
Nisse Preschool & Kids Place |
Partnership |
311 College Drive Decorah, IA 52101 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-26 |
Kathleen Schutte |
chelsea.whalen@upperiowains.com |
Decorah |
Winneshiek |
IA |
Michelle Ostern |
Robin C Schultz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kathleen Schutte |
chelsea.whalen@upperiowains.com |
Treasurer |
Decorah |
Winneshiek |
IA |
Michelle Ostern |
Robin C Schultz |
Signed |
140 |
2020-04-28 10:13 |
Anonymous (not verified) |
74.84.101.138 |
Lutheran Cemetery Association |
Proprietorship |
410 S. Mechanic Street Decorah, IA 52101 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-21 |
John D Noel |
chelsea.whalen@upperiowains.com |
Decorah |
Winneshiek |
IA |
Robin C Schultz |
Bobbi Jo Berg |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John D Noel |
chelsea.whalen@upperiowains.com |
President |
Decorah |
Winneshiek |
IA |
Robin C Schultz |
Bobbi Jo Berg |
Signed |
141 |
2020-04-28 10:14 |
Anonymous (not verified) |
74.84.101.138 |
Lutheran Cemetery Association |
Proprietorship |
410 S. Mechanic Street Decorah, IA 52101 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-02 |
Steven Matter |
chelsea.whalen@upperiowains.com |
Decorah |
Winneshiek |
IA |
Bobbi Jo Berg |
Robin C Schultz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steven Matter |
chelsea.whalen@upperiowains.com |
Secretary |
Decorah |
Winneshiek |
IA |
BOBBI JO BERG |
Robin C Schultz |
Signed |
142 |
2020-04-28 10:16 |
Anonymous (not verified) |
74.84.101.138 |
Lutheran Cemetery Association |
Proprietorship |
410 S. Mechanic Street Decorah, IA 52101 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-18 |
Timothy A Stoddard |
chelsea.whalen@upperiowains.com |
Decorah |
Winneshiek |
IA |
Robin C Schultz |
Bobbi Jo Berg |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy A Stoddard |
chelsea.whalen@upperiowains.com |
Treasurer |
Decorah |
Winneshiek |
IA |
Robin C Schultz |
Bobbi Jo Berg |
Signed |
143 |
2020-04-29 09:59 |
Anonymous (not verified) |
173.29.234.11 |
Plum Communications, LLC |
Limited Liability Company |
1018 NW Campus Ridge Court |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-29 |
Brian Shearer |
brian@plumllc.com |
Ankeny |
Polk |
Iowa |
Kathryn Shearer |
Emily Davis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Dean Shearer |
brian@plumllc.com |
Self |
Ankeny |
Polk |
Iowa |
Kathryn Shearer |
Emily Davis |
Signed |
144 |
2020-04-29 11:20 |
Anonymous (not verified) |
65.158.103.107 |
Symbiotic Gardens LLC |
Limited Liability Company |
3403 Dubuque Avenue Des Moines Iowa 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-29 |
Brandon Kam |
symbioticgardens@gmail.com |
Des Moines |
Polk |
Iowa |
Kathy Schulte |
Larry Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brandon Kam |
symbioticgardens@gmail.com |
same |
Des Moines |
Polk |
Iowa |
Kathy Schulte |
Larry Johnson |
Signed |
145 |
2020-04-30 16:09 |
Anonymous (not verified) |
173.191.206.253 |
Mark Knapp |
Proprietorship |
11244 Linden Rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-30 |
Mark A Knapp |
mlmlknapp@iowatelecom.net |
Linden |
Iowa |
United States |
Phil Hesseltine |
Kathy Hesseltine |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Knapp |
mlmlknapp@iowatelecom.net |
self |
Linden |
Iowa |
United States |
Phil Hesseltine |
Kathy Hesseltine |
Signed |
146 |
2020-05-01 05:34 |
Anonymous (not verified) |
174.217.5.175 |
Five Nail Services |
Limited Liability Company |
32379 162nd 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. |
2020-05-01 |
Ralph Chiodo |
rchiodo2@gmail.com |
Woodward |
IA |
United States |
Ralph Chiodo |
Rebecca Chiodo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ralph Chiodo |
rchiodo2@gmail.com |
Self |
Woodward |
IA |
United States |
Ralph Chiodo |
Rebecca Chiodo |
Signed |
147 |
2020-05-02 09:07 |
Anonymous (not verified) |
75.162.65.142 |
Tim Soy |
Proprietorship |
3506 Amherst 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. |
2020-05-01 |
Timothy Soy |
kingsoyboy@hotmail.com |
Des Moines |
Polk |
Iowa |
Aaron Page |
Jeremy Lukehart |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy Soy |
kingsoyboy@hotmail.com |
Self |
Des Moines |
Polk |
Iowa |
Aaron page |
Jeremy Lukehart |
Signed |
148 |
2020-05-04 15:49 |
Anonymous (not verified) |
173.28.28.57 |
LaRae Randall dba Wild Soul Photo |
Proprietorship |
19019 O Avenue, Grundy Center, IA 50638 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-27 |
LaRae Randall |
cmins_re@mchsi.com |
Grundy Center |
Grundy |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LaRae Randall |
cmins_re@mchsi.com |
Self |
Grundy Center |
Grundy |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
149 |
2020-05-06 08:33 |
Anonymous (not verified) |
66.188.136.150 |
Lacey Doyle |
Proprietorship |
210 Austin Ct. Apt 10 Epworth, IA 52045 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-05 |
Lacey Doyle |
kschumacher@tricorinsurance.com |
Epworth |
Dubuque |
IA |
Russell Masartis |
Rose Horstman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lacey Doyle |
kschumacher@tricorinsurance.com |
Same |
Epworth |
Dubuque |
IA |
Russell Masartis |
Rose Horstman |
Signed |
150 |
2020-05-06 10:59 |
Anonymous (not verified) |
76.190.229.163 |
RNR Holdings LLC |
Limited Liability Company |
4330 Winter Eagle Trail SE Apt B, Iowa City, Iowa 52240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-06 |
Richard E. White |
rwhite245@yahoo.com |
Hermitage |
Mercer |
Pennsylvania |
Gene Bell |
Victor J Veltri |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Richard E White |
rwhite245@yahoo.com |
Owner |
Hermitage |
Mercer |
Pennsylvania |
Gene Bell |
Victor J Veltri |
Signed |
151 |
2020-05-07 15:57 |
Anonymous (not verified) |
198.167.182.164 |
Hawk-I Trucking LLC |
Limited Liability Company |
521 Greenfield Dr, Tiffin, IA 52340 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-06 |
Chad Lee Freeman |
ricenogle@southslope.net |
Tiffin |
Johnson |
IA |
Scott Freeman |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chad Lee Freeman |
ricenogle@southslope.net |
Managing Member |
Tiffin |
Johnson |
IA |
Scott Freeman |
Dyan Kriener |
Signed |
152 |
2020-05-11 15:56 |
Anonymous (not verified) |
198.167.182.164 |
Hawk-I Trucking LLC |
Limited Liability Company |
521 Greenfield Dr, Tiffin, IA 52340 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-11 |
Tyler Rogers |
tylerrogersinc@yahoo.com |
Iowa City |
Johnson |
Iowa |
Scott Freeman |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tyler Rogers |
tylerrogersinc@yahoo.com |
Member |
Iowa City |
Johnson |
Iowa |
Scott Freeman |
Dyan Kriener |
Signed |
153 |
2020-05-12 12:58 |
Anonymous (not verified) |
172.58.86.150 |
Big Head Burger |
Limited Liability Company |
706 Quincy st. Waterloo, Iowa 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. |
(1) I am not electing the employers’ liability coverage. |
2020-05-12 |
David Westley Bryant |
questions.bhb@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Darlean Crawford |
Everlue Kincaid |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Westley Bryant |
questions.bhb@gmail.com |
Owner |
Waterloo |
Black Hawk |
Iowa |
Darlean Crawford |
Everlue Kincaid |
Signed |
154 |
2020-05-12 15:00 |
Anonymous (not verified) |
97.125.253.184 |
Rundle Creations |
Limited Liability Company |
5816 Urbandale Avenue, Des Moines, 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. |
2020-05-12 |
Mark Lavern Rundle II |
rundlecreations@gmail.com |
Des Moines |
Polk |
Iowa |
Luis Alex Jimenez |
Jennifer Lea Griffith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Erika Anne Rundle |
rundlecreations@gmail.com |
Co-Owner |
Des Moines |
Polk |
Iowa |
Luis Alex Jimenez |
Jennifer Lea Griffith |
Signed |
155 |
2020-05-12 17:03 |
Anonymous (not verified) |
173.17.184.241 |
Shelly Whalen |
Proprietorship |
1625 Darby Dr Waterloo IA 50702 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-12 |
Shelly Whalen |
swhalen90@hotmail.com |
Waterloo |
IA |
United States |
Taylor Whalen |
Todd Gerleman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shelly Whalen |
swhalen90@hotmail.com |
self employed |
Waterloo |
IA |
United States |
Taylor Whalen |
Todd Gerleman |
Signed |
156 |
2020-05-13 20:37 |
Anonymous (not verified) |
216.106.236.82 |
MR Electric LLC |
Limited Liability Company |
1853 230st Inwood, IA 51240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-13 |
Matthew Rozeboom |
matt.rozeboom@gmail.com |
Inwood |
Lyon |
Iowa |
Rachel Schruers |
Caitlin Fluit |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matt Rozeboom |
matt.rozeboom@gmail.com |
Owner/President |
Inwood |
Lyon |
Iowa |
Rachel Schruers |
Caitlin Fluit |
Signed |
157 |
2020-05-14 15:11 |
Anonymous (not verified) |
173.28.28.57 |
Brett Dix |
Proprietorship |
16696 245th Street, Aplington, IA 50604 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-30 |
Brett Dix |
cmins_re@mchsi.com |
Aplington |
Butler |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brett Dix |
cmins_re@mchsi.com |
Self |
Aplington |
Butler |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
159 |
2020-05-18 14:21 |
Anonymous (not verified) |
173.28.28.57 |
Matthew Klahsen |
Proprietorship |
1103 Gray Street, Aplington IA 50604 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-12 |
Matthew Klahsen |
cmins_re@mchsi.com |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Klahsen |
cmins_re@mchsi.com |
Self |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
160 |
2020-05-18 15:04 |
Anonymous (not verified) |
173.28.28.57 |
Angela Scanlan |
Proprietorship |
26436 320th Street, Parkersburg IA 50665 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-28 |
Angela Scanlan |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Angela Scanlan |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
161 |
2020-05-19 11:31 |
Anonymous (not verified) |
208.95.1.97 |
Paul McCoy DBA McCoy Contracting |
Proprietorship |
2806 Highway T47, Montour, Iowa 50173 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-19 |
Paul McCoy |
paulrmccoy1969@gmail.com |
Montour |
Tama |
Iowa |
Mike Thede |
Toni Chaska |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paul McCoy |
paulrmccoy1969@gmail.com |
Owner |
Montour |
Tama |
Iowa |
Mike Thede |
Toni Chaska |
Signed |
162 |
2020-05-19 15:03 |
Anonymous (not verified) |
67.212.114.80 |
Collum Plumbing, LLC |
Limited Liability Company |
610 West 20th Street, Cedar Falls, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-19 |
Stephen Collum |
collumplumbing@cfu.net |
Cedar Falls |
Iowa |
United States |
Mike Thode |
Linda Thode |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stephen Collum |
collumplumbing@cfu.net |
Member of LLC |
Cedar Falls |
Black Hawk |
Iowa |
Mike Thode |
Linda Thode |
Signed |
163 |
2020-05-20 11:58 |
Anonymous (not verified) |
173.27.1.111 |
David |
Proprietorship |
4023 E 28th st 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. |
2021-05-20 |
David Ortiz |
jdiconstrucction@gmail.com |
Des Moines |
Polk County |
Iowa |
Erika Olague |
Jieldh Ortiz-Olague |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Ortiz |
jdiconstrucction@gmail.com |
JDI Construction |
Des Moines |
Polk County |
Iowa |
Erika Olague |
Jieldh Ortiz-Olague |
Signed |
164 |
2020-05-26 10:30 |
Anonymous (not verified) |
166.182.80.35 |
T.W. Barton Restoration Service |
Proprietorship |
2704 Cass Avenue Mount Pleasant, Iowa 52641 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-26 |
Todd William Barton II |
twbartonrestoration@yahoo.com |
Mount Pleasant |
Henry |
Iowa |
Olivia Grace Barton |
Todd William Barton Sr. |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Todd William Barton II |
twbartonrestoration@yahoo.com |
Self |
Mount Pleasant |
Henry |
Iowa |
Olivia Grace Barton |
Todd William Barton Sr. |
Signed |
166 |
2020-05-27 11:48 |
Anonymous (not verified) |
66.188.136.150 |
Kevin Kerstetter |
Proprietorship |
1080 E 12th St. Dubuque, IA 52001 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-26 |
Kevin Kerstetter |
kschumacher@tricorinsurance.com |
Cuyahoga Falls |
Summit County |
OH |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kevin Kerstetter |
kschumacher@tricorinsurance.com |
Same |
Cuyahoga Falls |
Summit County |
OH |
Russell Masartis |
Nancy Wortley |
Signed |
167 |
2020-05-27 11:51 |
Anonymous (not verified) |
66.188.136.150 |
Dennis Heinlen |
Proprietorship |
3415 Upland Rd. Lowellville, OH |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-26 |
Dennis Heinlen |
kschumacher@tricorinsurance.com |
Lowellville |
Mahoning |
OH |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dennis Heinlen |
kschumacher@tricorinsurance.com |
Same |
Lowellville |
Mahoning |
OH |
Russell Masartis |
Nancy Wortley |
Signed |
168 |
2020-05-28 11:29 |
Anonymous (not verified) |
173.31.147.225 |
RECYCLED SPIRITS LLC |
Limited Liability Company |
43 ANN STREET MILFORD IA 51351 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-28 |
LACEY LAAKE |
BLAMB@SPENCERSCHOOLS.ORG |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LACEY LAAKE |
BLAMB@SPENCERSCHOOLS.ORG |
SELF |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
169 |
2020-05-28 11:31 |
Anonymous (not verified) |
173.31.147.225 |
RECYCLED SPIRITS LLC |
Limited Liability Company |
43 ANN ST MILFORD IA 51351 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-28 |
BETH LAMB |
BLAMB@SPENCERSCHOOLS.ORG |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
BETH LAMB |
BLAMB@SPENCERSCHOOLS.ORG |
SELF |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
170 |
2020-06-01 13:31 |
Anonymous (not verified) |
173.28.28.57 |
Rachel Poppens |
Proprietorship |
910 Parriott Street, Aplington IA 50604 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-19 |
Rachel Poppens |
cmins_re@mchsi.com |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rachel Poppens |
cmins_re@mchsi.com |
Self |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
171 |
2020-06-01 16:17 |
Anonymous (not verified) |
99.203.98.130 |
Jose Jurado |
Limited Liability Company |
3825 NE 43rd ct Des Moines IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-01 |
Jose Jurado |
trustedroofingllc@gmail.com |
Des Moines |
Polk |
IOWA |
Sterling Bean |
Sigifredo Corral |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Jurado |
trustedroofingllc@gmail.com |
Marcos Jurado |
Des Moines |
Polk |
IOWA |
Sterling Bean |
Sigifredo Corral |
Signed |
172 |
2020-06-02 15:56 |
Anonymous (not verified) |
66.188.136.150 |
David Bull |
Proprietorship |
221 N Aarlocker St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-02 |
David Bull |
kschumacher@tricorinsurance.com |
Mount Hope |
Grant |
WI |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Bull |
kschumacher@tricorinsurance.com |
Same |
Mount Hope |
Grant |
WI |
Russell Masartis |
Nancy Wortley |
Signed |
173 |
2020-06-04 11:22 |
Anonymous (not verified) |
167.142.93.121 |
Chad Hauschild dba Chad Hauschild Logging |
Proprietorship |
23864 190th St, Farmersburg, IA 52047 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-04 |
Chad Hauschild |
michael@giffordinsurance.net |
Farmersburg |
Clayton |
Iowa |
Angela Keppler |
Kevin Lau |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chad Hauschild |
michael@giffordinsurance.net |
Self |
Farmersburg |
Clayton |
Iowa |
Angela Keppler |
Kevin Lau |
Signed |
174 |
2020-06-05 15:10 |
Anonymous (not verified) |
98.21.202.208 |
Bloomfield Properties LLC |
Limited Liability Company |
206 Weaver Road, Bloomfield, IA 52537 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-05 |
Terri Roberts |
terri_roberts58@yahoo.com |
Ottumwa |
Wapello |
Iowa |
Sheri Moore |
Cassidy Dimmitt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Terri Roberts |
terri_roberts58@yahoo.com |
shareholder |
Ottumwa |
Wapello |
Iowa |
Sheri Moore |
Cassidy Dimmitt |
Signed |
175 |
2020-06-05 15:14 |
Anonymous (not verified) |
98.21.202.208 |
Bloomfield Properties LLC |
Limited Liability Company |
206 Weaver Road, Bloomfield, IA 52537 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-05 |
Dave Lawrence |
terri_roberts58@yahoo.com |
Ottumwa |
Wapello |
Iowa |
Sheri Moore |
Cassidy Dimmitt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Terri Roberts |
terri_roberts58@yahoo.com |
shareholder |
Ottumwa |
Wapello |
Iowa |
Sheri Moore |
Cassidy Dimmitt |
Signed |
176 |
2020-06-07 08:23 |
Anonymous (not verified) |
174.16.51.128 |
TrueFood LLC |
Limited Liability Company |
2055 Nature Ave Stanton IA 51573 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-24 |
Brian Barkman |
brian.barkman@truefood.farm |
Georgetown |
Williamson |
Texas |
Wanda Barkman |
Chelsea Church |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Barkman |
brian.barkman@truefood.farm |
TrueFood LLC is owned by agent |
Stanton |
Montgomery |
IA |
Wanda Barkman |
Chelsea Church |
Signed |
177 |
2020-06-08 11:00 |
Anonymous (not verified) |
173.28.28.57 |
Lakeview Retreat Center, LLC |
Limited Liability Company |
17726 260th Street, Aplington IA 50604 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-23 |
Kendale Winkowitsch |
cmins_re@mchsi.com |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kendale Winkowitsch |
cmins_re@mchsi.com |
Self |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
179 |
2020-06-09 11:22 |
Anonymous (not verified) |
173.31.147.225 |
SAUL GUERARA MEZA |
Proprietorship |
26 WESTVIEW DRIVE APT 5 MILFORD IA 51351 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-21 |
SAUL GUERARA MEZA |
ESMEJ2513@GMAIL.COM |
MILFORD |
DICKINSON |
IOWA |
ESMIRALDO JIMENEZ |
TAMI KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SAUL GUERARA MEZA |
ESMEJ2513@GMAIL.COM |
SELF |
MILFORD |
DICKINSON |
IOWA |
ESMIRALDO JIMENEZ |
TAMI KLEIN |
Signed |
180 |
2020-06-09 13:35 |
Anonymous (not verified) |
99.203.113.208 |
Z & Sons handyman company LLC |
Limited Liability Company |
2701 E Market St Des Moines Iowa 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-09 |
Miguel Angel Zuniga |
mazuniga123678@gmail.com |
Des Moines |
Polk |
Iowa |
Rosario Zuniga |
Christina Zuniga |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Miguel Angel Zuniga |
mazuniga123678@gmail.com |
Z & Sons handyman company LLC is owned by agent |
Des Moines |
Polj |
Iowa |
Rosario Zuniga |
Christina Zuniga |
Signed |
181 |
2020-06-09 20:44 |
Anonymous (not verified) |
75.162.15.198 |
Z & Sons handyman company LLC |
Limited Liability Company |
2701 E Market St Des Moines Iowa 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-09 |
Miguel Angel Zuniga |
mazuniga123678@gmail.com |
Des Moines |
Polk |
Iowa |
Rosario Zuniga |
Christina Zuniga |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Miguel Angel Zuniga |
mazuniga123678@gmail.com |
Z & Sons handyman company LLC is owned by agent |
Des Moines |
Polk |
Iowa |
Rosario Zuniga |
Christina Zuniga |
Signed |
182 |
2020-06-11 14:18 |
Anonymous (not verified) |
173.29.64.73 |
Diamond Builders of Davenport INC |
Proprietorship |
14358 275th St, Long grove, IA 52756 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-11 |
Paula Woods |
paulawoods@diamond-builders.com |
Long Grove |
IA |
United States |
Colin Woods |
Joe Roozeboom |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tyler Green |
tyler@porterinsuranceinc.com |
Insurance Agent |
Long Grove |
IA |
United States |
Colin Woods |
Joe Roozeboom |
Signed |
183 |
2020-06-12 08:23 |
Anonymous (not verified) |
107.77.173.7 |
A&W Marble & Tile |
Proprietorship |
5624 Sw 5Th Pl |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-12 |
Wayne A Yergy |
wyergy@gmail.com |
Des Moines |
IA |
United States |
Michael L Smith |
Guy B Chaney |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wayne Yergy |
wyergy@gmail.com |
Self |
Des Moines |
IA |
United States |
Michael L Smith |
Guy B Chaney |
Signed |
184 |
2020-06-12 10:38 |
Anonymous (not verified) |
174.243.112.246 |
brian kass |
Proprietorship |
15064 kass road |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-11 |
brian kass |
kass5kass@hotmail.com |
dubuque |
Iowa |
Iowa |
kelly kass |
jenny McIntyre |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
brian kass |
kass5kass@hotmail.com |
self |
dubuque |
Iowa |
iowa |
Kelly Kass |
Jenny McIntyre |
Signed |
185 |
2020-06-12 14:50 |
Anonymous (not verified) |
173.28.28.57 |
Aaron & Eliesa Thomas |
Partnership |
706 3rd Avenue, Parkersburg IA 50665 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-20 |
Aaron & Eliesa Thomas |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aaron & Eliesa Thomas |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
186 |
2020-06-15 08:03 |
Anonymous (not verified) |
66.188.136.150 |
Candace Dingler |
Proprietorship |
280 Trimble Station Road |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-10 |
Candace Dingler |
kschumacher@tricorinsurance.com |
Hogansville |
Troup |
GA |
Russell Masartis |
Angie Ords |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Candace Dingler |
kschumacher@tricorinsurance.com |
Same |
Hogansville |
Troup |
GA |
Russell Masartis |
Angie Ords |
Signed |
189 |
2020-06-16 16:24 |
Anonymous (not verified) |
173.28.58.2 |
Perry Engel |
Proprietorship |
140 2nd Ave NW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-12 |
Perry Engel |
HRSolutionsContracting@gmail.com |
Oelwein |
IA |
United States |
Danette Hager |
Tosha Medina |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Perry Engel |
HRSolutionsContracting@gmail.com |
Self |
Oelwein |
IA |
United States |
Danette Hager |
Tosha Medina |
Signed |
190 |
2020-06-19 11:08 |
Anonymous (not verified) |
107.77.207.128 |
PAT Construction |
Limited Liability Company |
6007 Sw 15th ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-21 |
Pablo Aguilar Tolentino |
PATConstruction77@gmail.com |
DES MOINES |
77 |
77 |
Trisha Resendiz |
Toni Lopez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Pablo Aguilar Tolentino |
PATconstruction77@gamil.com |
owner |
DES MOINES |
77 |
77 |
Trisha Resendiz |
Toni Lopez |
Signed |
191 |
2020-06-23 16:09 |
Anonymous (not verified) |
173.18.3.76 |
Look At You LLC |
Limited Liability Company |
5545 Mills Civic Pkwy Ste 100 West Des Moines, IA 50265 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-23 |
Amber Keppler |
keppler_ark@outlook.com |
Des Moines |
Polk |
IA |
Angela Kinsey |
Jon Stetzel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Amber Keppler |
keppler_ark@outlook.com |
LLC Member |
Des Moines |
Polk |
IA |
Angela Kinsey |
Jon Stetzel |
Signed |
192 |
2020-06-24 07:42 |
Anonymous (not verified) |
66.188.136.150 |
Paul Brickley |
Proprietorship |
558 Franklin Ave. 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. |
2020-06-23 |
Paul Brickley |
kschumacher@tricorinsurance.com |
Galesburg |
Knox |
IL |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paul Brickley |
kschumacher@tricorinsurance.com |
Same |
Galesburg |
Knox |
IL |
Russell Masartis |
Nancy Wortley |
Signed |
194 |
2020-06-24 15:24 |
Anonymous (not verified) |
173.16.140.254 |
Eugene Behle |
Proprietorship |
3134 6th 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. |
(1) I am not electing the employers’ liability coverage. |
2020-06-24 |
Eugene Behle III |
Bub4bme@gmail.com |
Des Moines |
Polk |
Iowa |
Kelly Coluzzi |
Mitch Coluzzi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Eugene Behle III |
Bub4bme@gmail.com |
Self |
Des Moines |
POLK |
Iowa |
Kelly Coluzzi |
Mitch Coluzzi |
Signed |
195 |
2020-06-29 08:55 |
Anonymous (not verified) |
107.77.173.23 |
E.S.T. Construction LLC |
Limited Liability Company |
2412 E 16th 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. |
2020-06-29 |
Eber Saul Torres |
estorres48@gmail.com |
Des Moines |
Polk |
Iowa |
Hailey Galdames Luna |
Abel Mejia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Eber Saul Torres |
estorres48@gmail.com |
Self |
Des Moines |
Polk |
IOWA |
Hailey Galdames Luna |
Abel Mejia |
Signed |
196 |
2020-06-30 23:17 |
Anonymous (not verified) |
72.46.186.211 |
Artie's Construction |
Proprietorship |
520 5th Ave Sibley, IA 51249 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-30 |
Gloria Esther Torres |
torrglo@hotmail.com |
Sibley |
Osceola |
Iowa |
Laura Barrie |
Morgen Gonzalez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gloria Esther Torres |
torrglo@hotmail.com |
Self |
Sibley |
Osceola |
Iowa |
Laura Barrie |
Morgen Gonzalez |
Signed |
197 |
2020-07-02 09:33 |
Anonymous (not verified) |
66.188.136.150 |
M & EM Trucking |
Proprietorship |
216 4th Ave SE Dyersville, IA 52040 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-02 |
Martin Funke |
kschumacher@tricorinsurance.com |
Dyersville |
Dubuque |
IA |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Martin Funke |
kschumacher@tricorinsurance.com |
Same |
Dyersville |
Dubuque |
IA |
Russell Masartis |
Nancy Wortley |
Signed |
198 |
2020-07-08 17:35 |
Anonymous (not verified) |
162.218.47.214 |
Olsem Aerial Application Services LLC |
Limited Liability Company |
34538 County Road 13 Westbrook MN 56183 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-08 |
Benjamin Olsem |
oaasllc@gmail.com |
Westbrook |
Cottonwood |
MN |
Megan Olsem |
Tobin Richards |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Benjamin Olsem |
oaasllc@gmail.com |
Owner/Self |
Westbrook |
Cottonwood |
MN |
Megan Olsem |
Tobin Richards |
Signed |
199 |
2020-07-09 10:49 |
Anonymous (not verified) |
167.142.98.40 |
Ryan Stott |
Proprietorship |
1513 Hawthorne 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. |
2020-07-09 |
Ryan Lynn Stott |
rlstott@hotmail.com |
Jefferson |
Greene |
Iowa |
Brock Chisum |
Brian Chisum |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Stott |
rlstott@hotmail.com |
self |
Jefferson |
Greene |
Iowa |
Brock Chisum |
Brian Chisum |
Signed |
200 |
2020-07-09 10:56 |
Anonymous (not verified) |
167.142.98.40 |
brian chisum |
Proprietorship |
168 c.r. 2007 valley view tx |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-09 |
brian chisum |
chisum413@gmail.com |
valley view |
cooke |
tx |
lakota larson |
john morland |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
brian chisum |
chisum413@gmail.com |
self |
valley view |
cooke |
tx |
lakota larson |
john morland |
Signed |
201 |
2020-07-09 11:07 |
Anonymous (not verified) |
167.142.98.40 |
Brock Chisum |
Proprietorship |
369 Wise Rd., Decatur, TX76234 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-09 |
Brock Chisum |
bchisum@hotmail.com |
Decatur, TX |
Wise |
Texas |
Lakota Larson |
Ryan Stott |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brock Chisum |
bchisum@hotmail.com |
Self |
Decatur |
Wise |
Texas |
Lakota Larson |
Ryan Stott |
Signed |
202 |
2020-07-10 15:30 |
Anonymous (not verified) |
50.82.95.247 |
Paulo De Oliveira |
Proprietorship |
466 Valeen In Belton, MO 64012 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-10 |
Paulo De Oliveira |
paulinhousa1981@gmail.com |
Belton |
Cass |
Missouri |
Deanna K Yersin |
Ryan S. Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paulo De Oliveira |
paulinhousa1981@gmail.com |
paulinhousa1981@gmail.com |
Belton |
Cass |
Missouri |
Deanna K Yersin |
Ryan S. Johnson |
Signed |
203 |
2020-07-15 09:39 |
Anonymous (not verified) |
166.181.66.222 |
High Caliber Fiber |
Limited Liability Company |
2958 110th ave masonville IA, 50654 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-15 |
Chris cooper |
chris_cooper@highcaliberfiber.com |
Masonville |
Delaware |
Iowa |
Nick beranek |
Nicole kintzle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chris Cooper |
chris_cooper@highcaliberfiber.com |
N/A |
Masonville |
Delaware |
Iowa |
Nick beranek |
Nicole kintzle |
Signed |
204 |
2020-07-15 11:21 |
Anonymous (not verified) |
63.152.54.222 |
Tim Duggan |
Limited Liability Company |
1405 1st St. SW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-15 |
Timothy M Duggan |
tdc.inc30@gmail.com |
Cedar Rapids |
Iowa |
United States |
Joe Willis |
Andrew Anson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy M Duggan |
tdc.inc30@gmail.com |
President |
Cedar Rapids |
Iowa |
United States |
Joe Willis |
Andrew Anson |
Signed |
205 |
2020-07-15 14:19 |
Anonymous (not verified) |
108.209.12.64 |
Sequoia integrative Medical Services |
Limited Liability Company |
1746 Paul Drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-15 |
Jennifer Christine VandenHeuvel |
jvandenheuvel@att.net |
Kaukauna |
WI |
United States |
David VandenHeuvel |
Pam Leplavy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jennifer Christine VandenHeuvel |
jvandenheuvel@att.net |
Owner |
Kaukauna |
WI |
United States |
David VandenHeuvel |
Pam Leplavy |
Signed |
206 |
2020-07-16 08:18 |
Anonymous (not verified) |
97.64.194.122 |
Tommy Messino |
Proprietorship |
205 S Taylor St., Cherry, IL 61317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-10 |
Tommy Messino |
kschumacher@tricorinsurance.com |
Cherry |
Bureau |
IL |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tommy Messino |
kschumacher@tricorinsurance.com |
Same |
Cherry |
Bureau |
IL |
Russell Masartis |
Shuree Behr |
Signed |
207 |
2020-07-16 13:05 |
Anonymous (not verified) |
173.16.140.254 |
Steve Kennedy |
Proprietorship |
5108 SW 13th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-16 |
Steve Kennedy |
stevekennedy@gmail.com |
Des Moines |
Polk |
Iowa |
Jen Echterling |
Jake Hibbert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steve Kennedy |
stevekennedy007@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Jen Echterling |
Jake Hibbert |
Signed |
208 |
2020-07-16 20:24 |
Anonymous (not verified) |
216.127.193.93 |
Sequoia Integrative Medical Services |
Limited Liability Company |
W2560 Birschbach Drive, Mount Calvary, WI, 53057 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-16 |
Chad Weston Gardner |
chadwestongardner@yahoo.com |
Mount Calvary |
Fond du Lac |
Wisconsin |
Emily Lucht |
Ron Carpenter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chad Weston Gardner |
chadwestongardner@yahoo.com |
Self |
Mount Calvary |
Fond du Lac |
Wisconsin |
Emily Lucht |
Ron Carpenter |
Signed |
209 |
2020-07-19 17:02 |
Anonymous (not verified) |
173.189.166.183 |
Merle Fox |
Proprietorship |
314 N Jackson St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-19 |
Merle T Fox |
merletravisfox.79@gmail.com |
Lisbon |
Linn |
Iowa |
Dustin Ohlfest |
Chelsea Brown |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Merle Fox |
merletravisfox.79@gmail.com |
self |
Lisbon |
Linn |
Iowa |
Dustin Ohlfest |
Chelsea Brown |
Signed |
210 |
2020-07-20 13:28 |
Anonymous (not verified) |
75.162.95.97 |
RM construction |
Proprietorship |
65 SE 5TH STREET APT 4 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. |
2020-07-20 |
Rafael Marquez |
marquezrafael1@outlook.com |
Des Moines |
Polk IOWA |
IOWA |
Richard Yanez |
Francisco Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rafael Marquez |
marquezrafael1@outlook.com |
owner |
Des Moines |
Polk |
IOWA |
Richard Yanez |
Francisco Garcia |
Signed |
211 |
2020-07-20 15:30 |
Anonymous (not verified) |
138.43.237.249 |
High Caliber Fiber |
Limited Liability Company |
2958 110th Ave Masonville IA 50654 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-20 |
Chris |
Chris_cooepr@highcaliberfiber.com |
masonville |
Delaware |
IA |
NIck Beranek |
Nicole KIntzle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chris Cooper |
Chris_cooper@highcaliberfiber.com |
Self |
Masonville |
Delaware |
IA |
Nick Beranek |
Nicole Kintzle |
Signed |
212 |
2020-07-20 16:43 |
Anonymous (not verified) |
97.64.164.30 |
Bernard L. Gradoville D.D.S. |
Proprietorship |
2800 Ingersoll 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. |
2020-07-20 |
Bernard Gradoville |
bgradoville@ingersollfamilydentistry.com |
Des Moines |
IA |
United States |
Tricia Wilson |
Jack Gradoville |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bernard Gradoville |
bgradoville@ingersollfamilydentistry.com |
self |
Des Moines |
IA |
United States |
Tricia Wilson |
Jack Gradoville |
Signed |