1202 |
2022-07-11 21:14 |
Anonymous (not verified) |
173.17.252.144 |
B SQUARED CONSTRUCTION |
Limited Liability Company |
3407 skyline 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. |
2022-07-11 |
MARC BROOKER |
BSquared066@gmail.com |
Des Moines |
United states |
IA |
marc brooker |
MARC BROOKER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MARC BROOKER |
BSquared066@gmail.com |
owner |
Des Moines |
IA |
IA |
MARC BROOKER |
MARC BROOKER |
Signed |
271 |
2020-09-27 20:30 |
Anonymous (not verified) |
173.17.8.56 |
Hutch's Parking Lot Sweeping Inc |
Limited Liability Company |
5235 Jennifer Dr Pleasant Hill, IA 50327 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-27 |
William E Hutchinson Jr |
btnwhutch@aol.com |
Pleasant Hill |
Polk |
Iowa |
Tracy Hutchinson |
Diana Benda |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William E Hutchinson Jr |
btnwhutch@aol.com |
Self |
Pleasant Hill |
Polk |
Iowa |
Tracy Hutchinson |
Diana Benda |
Signed |
1352 |
2022-10-31 19:35 |
Anonymous (not verified) |
173.17.8.56 |
Hutch's Parking Lot Sweeping INC |
Limited Liability Company |
5235 JENNIFER DR |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-31 |
Bill HUTCHINSON |
btnwhutch@aol.com |
PLEASANT HILL |
Iowa |
United States |
TRACY HUTCHINSON |
NIC HUTCHINSON |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bill HUTCHINSON |
btnwhutch@aol.com |
SELF |
PLEASANT HILL |
Iowa |
United States |
TRACY HUTCHINSON |
NIC HUTCHINSON |
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 |
714 |
2021-11-05 11:16 |
Anonymous (not verified) |
209.252.172.87 |
Branson Bult - Bults Flooring |
Proprietorship |
440 Memorial Dr Se Cedar Rapids, Ia 52403 |
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. |
2020-05-16 |
Branson Bult |
bultsfloorcovering@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Branson Bult |
bultsfloorcovering@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
1114 |
2022-05-17 15:30 |
Anonymous (not verified) |
67.212.117.198 |
Busta Painting |
Limited Liability Company |
610 W 26th st #1 Cedar Falls, IA 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-16 |
Evan Busta |
bustapainting@gmail.com |
Cedar Falls |
IA |
United States |
Tanner Heikens |
Garrett Burrack |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Evan Busta |
bustapainting@gmail.com |
Self Employeed |
Cedar Falls |
IA |
United States |
Tanner Heikens |
Garrett Burrack |
Signed |
608 |
2021-08-17 21:35 |
Anonymous (not verified) |
50.82.65.174 |
33z Racing, LLC |
Limited Liability Company |
307 N Park Ave, New Sharon, IA. 50207 |
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. |
2021-08-17 |
James D VanderBeek |
jvanderbeek@plbci.com |
New Sharon |
Mahaska |
IA |
Barbara M VanderBeek |
Zackery James VanderBeek |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Barbara M VanderBeek |
bvanderbeek33z@gmail.com |
Spouse |
New Sharon |
Mahaska |
IA |
James D VanderBeek |
Zackery J VanderBeek |
Signed |
609 |
2021-08-17 21:42 |
Anonymous (not verified) |
50.82.65.174 |
33z Racing, LLC |
Limited Liability Company |
307 N Park Ave, New Sharon, IA. 50207 |
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. |
2021-08-17 |
Zackery James VanderBeek |
zackvanderbeek@gmail.com |
New Sharon |
Mahaska |
IA |
Barbara M VanderBeek |
James. VanderBeek |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Barbara M VanderBeek |
bvanderbeek33z@gmail.com |
Mother |
New Sharon |
Mahaska |
IA |
James D VanderBeek |
Barbara M VanderBeek |
Signed |
612 |
2021-08-19 21:50 |
Anonymous (not verified) |
50.82.65.174 |
33z Racing,, LLC |
Limited Liability Company |
307 N Park Ave, New Sharon, Iowa 50207 |
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. |
2021-08-20 |
James Dean VanderBeek |
jvanderbeek@plbco.com |
New Sharon |
Mahaska |
Iowa |
Margaret Ratcliff |
Billy Blake |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Barbara M VanderBeek |
bvanderbeek33z@gmail.com |
Spouse |
New Sharon |
Mahaska |
Iowa |
Margaret Ratcliff |
Billy Blake |
Signed |
613 |
2021-08-19 21:54 |
Anonymous (not verified) |
50.82.65.174 |
33z Racing, LLC |
Limited Liability Company |
307 N Park Ave, New Sharon, Iowa 50207 |
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. |
2021-08-20 |
Zackery J VanderBeek |
zackvanderbeek@gmail.com |
New Sharon |
Mahaska |
IA |
Margaret Ratcliff |
Billy Blake |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Barbara M VanderBeek |
bvanderbeek33z@gmail.com |
Mother |
New Sharon |
Mahaska |
IA |
Margaret Ratcliff |
Billy Blake |
Signed |
441 |
2021-03-18 16:20 |
Anonymous (not verified) |
173.25.156.33 |
CYALCO AVIATION LLC |
Limited Liability Company |
3710 W. MILWAUKEE ST, SPENCER, IA 51301 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-03-18 |
WILLIAM A. VAN LENT |
bvl@veridian.net |
WEST DES MOINES |
POLK |
IOWA |
ERIN MONFORT NELSON |
COLE M. VAN LENT |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
WILLIAM A. VAN LENT |
bvl@veridian.net |
SAME |
WEST DES MOINES |
POLK |
IOWA |
ERIN MONFORT NELSON |
COLE M. VAN LENT |
Signed |
896 |
2022-02-04 11:58 |
Anonymous (not verified) |
198.167.180.146 |
Northtowne Market Lot 7, LLC |
Limited Liability Company |
1005 Blairs Ferry Road NE, Cedar Rapids, IA 52404 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-04 |
Benjamin Wickum |
bwickum@collinscu.org |
CEDAR RAPIDS |
Linn |
Iowa |
Jody Comried |
Pat Milke |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Benjamin Wickum |
bwickum@collinscu.org |
Manager |
Cedar Rapids |
Linn |
Iowa |
Jody Comried |
Pat Milke |
Signed |
1475 |
2023-02-21 18:42 |
Anonymous (not verified) |
94.188.207.230 |
Michael Goodyk Consgtruction |
Proprietorship |
2392 Keokuk Drive Pella, Iowa. 50219 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-20 |
Michael Jay Goodyk |
mikegoodyk@gmail.com |
Pella |
Marion |
Iowa |
Joy Ekloffe |
Rick Ekloffe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gorp Edwards insurance |
bwilliams@vangorpins.com |
Insurance Agent |
Pella |
Marion |
Iowa |
Joy Ekloffe |
Rick Ekloffe |
Signed |
1443 |
2023-02-07 10:05 |
Anonymous (not verified) |
166.181.84.211 |
Leaf home solutions |
Limited Liability Company |
1595 Georgetown rd Hudson Ohio 44236 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-07 |
Dean Martells |
dn.mardesconstruction@gmail.com |
Laporte city |
Benton |
Ia |
Jeromia wilson |
Todd mcknees |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Yurko |
byurko@leacome.com |
Recruiter |
Hudson |
Summit |
Ohio |
Brian mako |
Mat kaulig |
Signed |
1434 |
2023-01-31 07:12 |
Anonymous (not verified) |
162.233.75.173 |
abc |
Proprietorship |
1122 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-31 |
Brian Yurko |
byurko714@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
pete |
re pete |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LHE |
byurko@leafhome.com |
contractor |
Deerfield Beach |
Florida |
United States |
pete |
re pete |
Signed |
1436 |
2023-02-01 11:53 |
Anonymous (not verified) |
174.215.242.112 |
Leaf home solutions |
Limited Liability Company |
1595 Georgetown Rd. Hudson, Ohio 44236 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-01 |
Edward Koch |
etkdbq@aol.com |
Waterloo |
IA |
United States |
Glenda mclarty |
Coen Koch |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian yurko |
byurko@leafhome.com |
Recruiter |
Hudson |
Summit |
Ohio |
Brian Mako |
Matt kaulig |
Signed |
1623 |
2023-05-02 14:09 |
Anonymous (not verified) |
94.188.207.226 |
Leafhome Solutions LLC |
Limited Liability Company |
1595 Georgetown Road Hudson, Ohio 44236 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-02 |
Grant Anders Scott |
G2designLLC@yahoo.com |
Des Moines |
Polk |
Iowa |
Katherine Scott |
Brian Yurko |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Yurko |
byurko@leafhome.com |
Recruiter |
Hudson |
Summit |
Ohio |
Katherine Scott |
Grant Scott |
Signed |
467 |
2021-04-10 12:21 |
Anonymous (not verified) |
24.252.54.168 |
Dave and Nancy Preucil Inc. |
Proprietorship |
13585 Clearview 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. |
2021-04-10 |
Domenico Zurini II |
davesspeedwaydz@gmail.com |
Council Bluffs |
IA |
United States |
Irven Saar II |
Jeffrey Hanke |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Barbi Zurini |
bzurini@gmail.com |
Wife |
Council Bluffs |
IA |
United States |
Irven Saar II |
Jeffrey Hanke |
Signed |
1011 |
2022-03-28 10:25 |
Anonymous (not verified) |
207.199.231.172 |
Brian Carmer |
Proprietorship |
133 S Iowa Ave, Ottumwa, IA 52501 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-28 |
Brian Carmer |
b_carmer@yahoo.com |
Ottumwa |
Wapello |
Iowa |
James Anderson |
Ashley Bryan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Carmer |
B_Carmer@yahoo.com |
Self |
Ottumwa |
Wapello |
Iowa |
James Anderson |
Ashley Bryan |
Signed |
1879 |
2023-10-26 13:17 |
Anonymous (not verified) |
94.188.207.224 |
CR Exteriors |
Proprietorship |
1636 Parktown Ct NE Unit 9 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-26 |
corey becker |
cab222.ab@gmail.com |
cedar rapids |
linn |
iowa |
Brian Ashlock |
Brian Coover |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Corey Becker |
cab222.ab@gmail.com |
same |
Cedar Rapids |
Linn |
Iowa |
Brian Ashlock |
Brian Coover |
Signed |
1280 |
2022-08-22 15:48 |
Anonymous (not verified) |
104.222.83.187 |
Cabinet Kulture LLC |
Limited Liability Company |
927 N. West St. Carroll, 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. |
2022-08-22 |
Jordan Ellis |
cabinetkulture@gmail.com |
Carroll |
IA |
United States |
Morgan Ellis |
Ryan Winkelman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cabinet Kulture LLC |
cabinetkulture@gmail.com |
Same person |
Carroll |
IA |
United States |
Morgan Ellis |
Ryan Winkelman |
Signed |
1062 |
2022-04-20 06:46 |
Anonymous (not verified) |
38.121.112.209 |
Cabinets and Closets by Design LLC |
Limited Liability Company |
18409 250th Street, Council Bluffs, IA 51503 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-18 |
Timothy Slobodnik |
cabinetsandclosetsbydesign@gmail.com |
Council Bluffs |
Pottawattamie |
IA |
Tom Pieper |
Jim Sietsema |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy Slobodnik |
cabinetsandclosetsbydesign@gmail.com |
self |
Council Bluffs |
Pottawattamie |
IA |
Tom Pieper |
Jim Sietsema |
Signed |
1294 |
2022-09-04 18:09 |
Anonymous (not verified) |
38.121.112.25 |
Cabinets and Closets by Design LLC |
Limited Liability Company |
18409 250th Street, Council Bluffs, IA 51503 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-04 |
TIMOTHY SLOBODNIK |
cabinetsandclosetsbydesign@gmail.com |
COUNCIL BLUFFS |
IA |
United States |
Jim Sietsema |
Jeff Deramcy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
TIMOTHY SLOBODNIK |
cabinetsandclosetsbydesign@gmail.com |
self |
COUNCIL BLUFFS |
IA |
United States |
TIMOTHY SLOBODNIK |
TIMOTHY SLOBODNIK |
Signed |
1414 |
2023-01-07 22:14 |
Anonymous (not verified) |
38.121.112.25 |
Cabinets and Closets by Design LLC |
Proprietorship |
18409 250th Street, 430 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-07 |
TIMOTHY SLOBODNIK |
cabinetsandclosetsbydesign@gmail.com |
COUNCIL BLUFFS |
IA |
United States |
Jim Sietsema |
Jeff Deramcy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
TIMOTHY SLOBODNIK |
cabinetsandclosetsbydesign@gmail.com |
self |
COUNCIL BLUFFS |
IA |
United States |
TIMOTHY SLOBODNIK |
TIMOTHY SLOBODNIK |
Signed |
266 |
2020-09-21 18:08 |
Anonymous (not verified) |
174.126.94.77 |
Club Fantasy Inc. |
Limited Liability Company |
P.O. Box 5115 Sioux City Iowa 51102 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-21 |
Curtis A. Behr |
cacbehr@aol.com |
Sioux City |
Woodbury |
Iowa |
Carter Vahle |
Dawn Meyer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Curtis A. Behr |
cacbehr@aol.com |
Self |
Sioux City |
Woodbury |
Iowa |
Carter Vahle |
Dawn Meyer |
Signed |
1191 |
2022-07-07 12:15 |
Anonymous (not verified) |
207.177.48.254 |
Day Ag Service LLC |
Proprietorship |
28250 240th Street Dallas Center, IA 50063 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-07 |
Calvin Brewer Day |
cal.d.day@gmail.com |
Dallas Center |
Dallas |
IA |
Dale Day |
Mary Beth Day |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Calvin Brewer Day |
cal.b.day@gmail.com |
Self |
Dallas Center |
Dallas |
IA |
Dale Day |
Mary Beth Day |
Signed |
1085 |
2022-05-03 10:38 |
Anonymous (not verified) |
65.144.174.26 |
Caleb Schroeder |
Proprietorship |
4051 SW 56th St Des Moines, IA 50321 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-03 |
Caleb Schroeder |
calebpschroeder@gmail.com |
Des Moines |
Polk |
Iowa |
Michele Schroeder |
Donald Schroeder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Caleb Schroeder |
calebpschroeder@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Michele Schroeder |
Donald Schroeder |
Signed |
1183 |
2022-07-06 13:43 |
Anonymous (not verified) |
50.82.95.247 |
2DL Construction, LLC |
Limited Liability Company |
1134 21st Street, Des Moines, IA 50311 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-06 |
Diego Lopez |
calihernandez01@icloud.com |
Des Moines |
Polk |
Iowa |
Ryan Johnson |
Deanna Yersin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Diego Lopez |
calihernandez01@icloud.com |
Self |
Des Moines |
Polk |
Iowa |
Ryan Johnson |
Deanna Yersin |
Signed |
226 |
2020-08-07 11:37 |
Anonymous (not verified) |
71.39.227.238 |
Clinton Luellen |
Proprietorship |
18591 N Ave, Minburn, IA 50167 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-07 |
Clinton Luellen |
CALuellen@gmail.com |
Minburn |
Dallas |
Iowa |
Winette Luellen |
Don Richardson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Clinton Luellen |
CALuellen@gmail.com |
Self |
Minburn |
Dallas |
Iowa |
Winette Luellen |
Don Richardson |
Signed |
217 |
2020-07-27 14:56 |
Anonymous (not verified) |
72.2.163.232 |
Calvin Kroger |
Proprietorship |
48232 292nd St. Hudson, SD 57034 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-27 |
Calvin Kroger |
calvinkroger@gmail.com |
Hudson |
Lincoln |
South Dakota |
Robin Anderson |
Adam Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Calvin Kroger |
calvinkroger@gmail.com |
proprietor |
Hudson |
Lincoln |
South Dakota |
Robin Anderson |
Adam Anderson |
Signed |
805 |
2021-12-20 08:40 |
Anonymous (not verified) |
65.144.174.26 |
TILE DECOR INC |
Proprietorship |
1702 WEST 3RD ST PERRY, IA 50220 |
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. |
2021-12-17 |
HUGO COJON |
CAMEYHUGO@GMAIL.COM |
PERRY |
DALLAS |
IOWA |
GABRIELA PEREZ |
NARCISO HIDALGO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
HUGO COJON |
CAMEYHUGO@GMAIL.COM |
OWNER |
PERRY |
DALLAS |
IOWA |
GABRIELA PEREZ |
NARCISO HIDALGO |
Signed |
775 |
2021-12-02 11:40 |
Anonymous (not verified) |
65.144.174.26 |
Pedro Campos |
Proprietorship |
16901 SW 13th St, Des Moines, IA 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-02 |
Pedro Campos |
camposp113@msn.com |
Des Moines |
Polk |
IA |
Antonio Campos |
Daniel Perez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Pedro Campos |
camposp113@msn.com |
Self |
Des Moines |
Polk |
Iowa |
Antonio Campos |
Daniel Perez |
Signed |
1023 |
2022-03-31 10:34 |
Anonymous (not verified) |
173.23.251.188 |
Thede Home Improvement |
Proprietorship |
1940 86th St Windsor Heights, IA 50324 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-31 |
Cameron Thede |
camthede22@gmail.com |
Windsor Heitghts |
Polk |
IA |
Tara Murphy |
Mike Ryerson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cameron Thede |
camthede22@gmail.com |
owner |
Windsor Heights |
Polk |
IA |
Tara Murphy |
Mike Ryerson |
Signed |
918 |
2022-02-16 14:23 |
Anonymous (not verified) |
172.58.22.152 |
RICK MYSAK LLC |
Limited Liability Company |
2220 GREY WOLF, HIAWATHA, IA 52233 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-16 |
RICK MYSAK |
camysak@gmail.com |
Hiawatha |
LINN |
IOWA |
Carrie Mysak |
RICK DeNEVE |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RICK MYSAK |
camysak@gmail.com |
SELF |
Hiawatha |
LINN |
IOWA |
Carrie Mysak |
RICK DeNEVE |
Signed |
86 |
2020-03-09 08:19 |
Anonymous (not verified) |
198.167.182.164 |
Simply Anchored LLC dba Simply Mae's |
Limited Liability Company |
601 Broad St, Story City, IA 50248 |
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 |
Cande Coulter |
cande@simplymaes.com |
Story City |
Story |
Iowa |
Lynn McKinney |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Candy Coulter |
cande@simplymaes.com |
Managing Member |
Story City |
Story |
Iowa |
Lynn McKinney |
Dyan Kriener |
Signed |
601 |
2021-08-12 16:37 |
Anonymous (not verified) |
172.58.83.7 |
C & G Construction LLC |
Limited Liability Company |
659 Sw Springfield Dr |
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. |
2021-08-12 |
Griselda Corona |
candgconst@gmail.com |
Ankeny |
Polk |
IA |
Clifton Kinney |
Marisol Chavira |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Juan Carlos corona |
candgconst@gmail.com |
Partner |
Ankeny |
Polk |
IA |
Clifton Kinney |
Marisol Chavira |
Signed |
1811 |
2023-08-21 17:03 |
Anonymous (not verified) |
94.188.205.167 |
Cardinal Concrete LLC |
Limited Liability Company |
503 17th St Boone, IA 50036 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-21 |
Ryan Woods |
cardinalconcrete.cw@gmail.com |
Boone |
Boone |
Iowa |
Jon Buller |
Terry Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Woods |
cardinalconcrete.cw@gmail.com |
100% owner |
Boone |
Boone |
Iowa |
Jon Buller |
Terry Miles |
Signed |
1210 |
2022-07-18 08:15 |
Anonymous (not verified) |
173.22.187.234 |
Cardinal Rule Handyman Services, LLC |
Limited Liability Company |
1304 E 10th St S, Newton, IA 50208 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-18 |
James Andrew Dunlap |
cardinarulehandyman@gmail.com |
Newton |
Jasper |
Iowa |
Jacinda Marie Dunlap |
James Thornton Dunlap |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Andrew Dunlap |
cardinalrulehandyman@gmail.com |
I am the authorized agent |
Newton |
Jasper |
Iowa |
Jacinda Marie Dunlap |
James Thornton Dunlap |
Signed |
1116 |
2022-05-17 21:41 |
Anonymous (not verified) |
75.162.182.172 |
Hinds Metal Designs LLC |
Limited Liability Company |
11409 Dakota St, Norwalk, IA 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-18 |
Brad Hinds |
bahinds@msn.com |
Norwalk |
Iowa |
Iowa |
Trevor Masten |
Travis Masten |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Carlene Hinds |
carlene4082@msn.com |
Self |
Norwalk |
Iowa |
Iowa |
Trevor Masten |
Travis Masten |
Signed |
958 |
2022-03-08 20:17 |
Anonymous (not verified) |
50.82.39.158 |
Ramos Drywall |
Limited Liability Company |
1355 Ozark Ridge, Coralville, IA 52241 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-03-08 |
Carlos Rene Ramos Martinez |
carlosramos2345@gmail.com |
Coralville |
Iowa |
United States |
Breanna Barragan |
Eliseo Tapia JR. |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Carlos Rene Ramos Martinez |
carlosramos2345@gmail.com |
N/A- Same Person |
Coralville |
Johnson County |
IA |
Breanna Barragan |
Eliseo Tapia JR. |
Signed |
2207 |
2024-05-07 09:44 |
Anonymous (not verified) |
94.188.207.226 |
Rodrimart brothers corp |
Limited Liability Company |
958 8th ave nw Altoona 50009 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-07 |
Enrique Rodriguez |
carluto_1983@hotmail.com |
Altoona |
Polk |
Iowa |
Adan boge |
Lonce wester |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Enrique Rodriguez |
carluto_1983@hotmail.com |
President |
Altoona |
Polk |
Iowa |
Adan boge |
Leans wester |
Signed |
1637 |
2023-05-10 15:39 |
Anonymous (not verified) |
94.188.207.230 |
Carly Roskop |
Proprietorship |
7706 Hampshire Ct NE Cedar Rapids, IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-10 |
Carly Roskop |
carlyroskop@gmail.com |
Cedar Rapids |
IA |
United States |
Dustin Roskop |
Tracy Petrak |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Carly Roskop |
carlyroskop@gmail.com |
Self |
Cedar Rapids |
IA |
United States |
Dustin Roskop |
Tracy Petrak |
Signed |
2017 |
2024-02-01 15:23 |
Anonymous (not verified) |
94.188.205.174 |
SolQ, LLC |
Limited Liability Company |
184 N 100 E Suite A Logan UT 84321 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-01 |
Casey Ryan Winger |
casey@solq.com |
Providence |
Cache |
UT |
Perry M. Koger |
Rebecca Koger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Casey Ryan Winger |
casey@solq.com |
Owner |
Providence |
Cache |
Utah |
Perry M. Koger |
Rebecca Koger |
Signed |
463 |
2021-04-06 21:34 |
Anonymous (not verified) |
173.23.145.187 |
LANTZ ELITE CARPENTRY & CONSTRUCTION INC |
Limited Liability Company |
1980 NW 94th St, Ste C Clive, IA 50325 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-01 |
Jose J. Castillo |
castillojosejonathan7@gmail.com |
Des Moines |
Polk |
IOWA |
PERLA LANDAVERDE |
ALMA J. GAYTAN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JOSE J. CASTILLO |
CASTILLOJOSEJONATHAN7@GMAIL.COM |
self |
Des Moines |
Iowa |
IOWA |
PERLA LANDAVERDE |
ALMA J. GAYTAN |
Signed |
2203 |
2024-05-06 12:44 |
Anonymous (not verified) |
94.188.207.228 |
Cma landimprovments |
Limited Liability Company |
530 50th pleasantville |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-06 |
Cody authier |
cauthier85@gmail.com |
Pleasantville |
Marion |
Iowa |
Melissa authier |
Valerie vanhelten |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cody authier |
cauthier85@gmail.com |
Self |
Pleasantville |
Marion |
Iowa |
Melissa authier |
Valerie vanhelten |
Signed |
1401 |
2022-12-23 09:07 |
Anonymous (not verified) |
75.162.43.221 |
Capital Express |
Limited Liability Company |
Council is Chris Blunk out of omaha NB. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-09-09 |
Nicholas Michelfelder |
nicmichelfelder@gmail.com |
8018 Valdez Circle |
polk |
iowa |
Ted Michelfelder |
lucy Sanderson |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Chris Blunk |
cblunk@harrislawomaha.com |
None |
1400 SE gateway Dr. 105 |
Polk |
IA |
Theodore Michelfelder |
Rick Isacson |
Signed |
1467 |
2023-02-17 16:14 |
Anonymous (not verified) |
94.188.205.169 |
H & C Construction |
Limited Liability Company |
708 Vine Street Lucas IA 50151 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-17 |
Colton Charles Clarke |
ccclarke95@gmail.com |
Truro |
IA |
United States |
Hailey Sullivan |
Shelby Comer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
H & C Construction |
ccclarke95@gmail.com |
Manager |
Truro |
IA |
United States |
Hailey Sullivan |
Shelby Comer |
Signed |
1508 |
2023-03-09 10:34 |
Anonymous (not verified) |
94.188.205.176 |
H & C Construction |
Limited Liability Company |
708 Vine Street Lucas IA 50151 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-09 |
Colton Charles Clarke |
ccclarke95@gmail.com |
Truro |
IA |
United States |
Hailey A Sullivan |
Shelby Comer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Colton Charles Clarke |
ccclarke95@gmail.com |
Manager |
Truro |
IA |
United States |
Hailey A Sullivan |
Shelby Comer |
Signed |
364 |
2021-01-14 13:46 |
Anonymous (not verified) |
173.31.147.225 |
JMAHER LLC |
Limited Liability Company |
907 4TH AVE SPENCER, IA 51301 |
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. |
2021-01-14 |
JUSTIN MAHER |
CCRIOWA@GMAIL.COM |
SPIRIT LAKE |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JUSTIN MAHER |
CCRIOWA@GMAIL.COM |
SELF |
SPIRIT LAKE |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
485 |
2021-04-16 11:58 |
Anonymous (not verified) |
69.57.23.123 |
CRAIG AUKES |
Proprietorship |
43397 50TH AVENUE, BUFFALO CENTER, IA 50424 |
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. |
2021-04-16 |
CRAIG AUKES |
cdaukes@yahoo.com |
Buffalo Center |
Winnebago |
Iowa |
Steven Heyer |
Cindy Mawdsley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
CRAIG AUKES |
cdaukes@yahoo.com |
Employer-Proprietor |
Buffalo Center |
Winnebago |
IA |
Steven Heyer |
Cindy Mawdsley |
Signed |
817 |
2021-12-30 12:58 |
Anonymous (not verified) |
50.80.80.37 |
Leaf Filter |
Limited Liability Company |
1595 Georgetown Road Hudson, OH 44236 |
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. |
2021-12-30 |
Kenneth Van Hook |
kennyvanhook1976@gmail.com |
Port Byron |
Rock Island |
IL |
Sharon Van Hook |
Judy Hoffman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cody Dunbar |
cdunbar@leaffilter.com |
Manager |
Bettendorf |
Scott County |
IA |
Cody Dunbar |
Jordan Nisiewicz |
Signed |
1006 |
2022-03-25 10:26 |
Anonymous (not verified) |
107.115.239.110 |
Jesus ojeda |
Limited Liability Company |
866 40th Ave Bettendorf IA 52722 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-25 |
Jesus Ojeda |
jesusojeda386@gmail.com |
2112 20 1/2 Ave Rock Island 61201 |
United States |
Illinois |
Cody Dunbar |
Tiffani branham |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cody Dunbar |
cdunbar@leaffilter.com |
Install manager |
866 40th Ave Bettendorf IA 52722 |
United States |
Iowa |
Jordan Nisiewicz |
Tiffani Branham |
Signed |
1212 |
2022-07-19 10:15 |
Anonymous (not verified) |
174.209.40.210 |
James holmes |
Proprietorship |
866 40th Ave bettendorf IA 52722 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-19 |
James holmes |
jrholmes1958@gmail.com |
Moline |
Rock island |
Il |
Tiffani branham |
Cody dunbar |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Leaffilter north llc |
cdunbar@leaffilter.com |
Install manager |
Bettendorf |
Scott |
Ia |
Cody dunbar |
Tiffani branham |
Signed |
1218 |
2022-07-21 10:55 |
Anonymous (not verified) |
173.27.17.3 |
LeafFilter North LLC |
Proprietorship |
Bettendorf |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-21 |
Craig Stang |
stangcraig@gmail.com |
Silvis |
Rock island |
IL |
Cody Dunbar |
Tiffani Branham |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LeafFilter North LLC |
cdunbar@leaffilter.com |
Install manager |
Bettendorf |
Iowa |
United States |
Cody dunbar |
Tiffani Branham |
Signed |
1227 |
2022-07-26 09:20 |
Anonymous (not verified) |
173.27.17.3 |
LeafFilter North LLC |
Proprietorship |
866 40th Ave bettendorf IA 52722 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-26 |
Craig Stang |
stangcraig@gmail.com |
Moline |
Rock island |
IL |
Cody Dunbar |
Tiffani Branham |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LeafFilter North LLC |
cdunbar@leaffilter.com |
Install manager |
Bettendorf |
Iowa |
United States |
Cody dunbar |
Tiffani Branham |
Signed |
1848 |
2023-09-19 10:20 |
Anonymous (not verified) |
94.188.207.226 |
Josh Woodworth |
Proprietorship |
16405 u.s. 67 milan il 61264 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-19 |
Josh woodworth |
joshwoodworth84@live.com |
milan |
Rock island |
Illinois |
Cody dunbar |
Jordan nisiewicz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cody dunbar |
cdunbar@leaffilter.com |
Install manager |
moline |
Rock island |
illinois |
Cody dunbar |
Jordan nisiewic |
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 |
2166 |
2024-04-20 13:38 |
Anonymous (not verified) |
94.188.205.175 |
Cedar Valley Seamless, LLC |
Limited Liability Company |
1184 215th St, Jesup, IA 50648 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-20 |
Andrew Richard Trumbauer |
cedarvalleyseamlessllc@gmail.com |
Jesup |
Buchanan |
Iowa |
James William Masteller |
Andrew William Hamilton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andrew Richard Trumbauer |
cedarvalleyseamlessllc@gmail.com |
Owner/Operator |
Jesup |
Buchanan |
Iowa |
James William Masteller |
Andrew William Hamilton |
Signed |
1229 |
2022-07-26 15:56 |
Anonymous (not verified) |
173.31.102.238 |
Rai Neu Jo LLC |
Limited Liability Company |
957 Westwood Dr NW Cedar Rapids, Iowa 52405 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-26 |
Craig Edward Johnson |
cejohnson119@yahoo.com |
Cedar Rapids |
Linn |
Iowa |
Becky Lynn Johnson |
Patricia Ann Coghlan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Craig Edward Johnson |
cejohnson119@yahoo.com |
Same person |
Cedar Rapids |
Linn |
Iowa |
Becky Lynn Johnson |
Patricia Ann Coghlan |
Signed |
1056 |
2022-04-18 12:04 |
Anonymous (not verified) |
63.152.56.49 |
Milo’s Construction |
Limited Liability Company |
8 Erobi ln Iowa city IA 52240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-18 |
Adriana Celis |
celisary0501@gmail.com |
Iowa city |
Johnson |
Iowa |
Arcelia Gómez |
Karina Beltrán |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Milo’s Construction |
celisary0501@gmail.com |
Owner |
Iowa city |
Johnson |
Iowa |
Arcelia Gómez |
Karina Beltrán |
Signed |
1581 |
2023-04-18 14:04 |
Anonymous (not verified) |
94.188.205.177 |
L&J Services LLC |
Limited Liability Company |
6 highland acres rd marshalltown iowa 50158 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-18 |
Josh Colwell |
centraliowa@fibrenew.com |
Marshalltown |
IA |
United States |
Micah Hesse |
Hunter Bolinsger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Colwell |
centraliowa@fibrenew.com |
Owner |
Marshalltown |
IA |
United States |
Micah Hesse |
Hunter Bolsinger |
Signed |
1582 |
2023-04-18 14:04 |
Anonymous (not verified) |
94.188.205.177 |
L&J Services LLC |
Limited Liability Company |
6 highland acres rd marshalltown iowa 50158 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-18 |
Josh Colwell |
centraliowa@fibrenew.com |
Marshalltown |
IA |
United States |
Micah Hesse |
Hunter Bolinsger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Colwell |
centraliowa@fibrenew.com |
Owner |
Marshalltown |
IA |
United States |
Micah Hesse |
Hunter Bolsinger |
Signed |
1583 |
2023-04-18 14:04 |
Anonymous (not verified) |
94.188.205.166 |
L&J Services LLC |
Limited Liability Company |
6 highland acres rd marshalltown iowa 50158 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-18 |
Josh Colwell |
centraliowa@fibrenew.com |
Marshalltown |
IA |
United States |
Micah Hesse |
Hunter Bolinsger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Colwell |
centraliowa@fibrenew.com |
Owner |
Marshalltown |
IA |
United States |
Micah Hesse |
Hunter Bolsinger |
Signed |
1584 |
2023-04-18 14:04 |
Anonymous (not verified) |
94.188.205.166 |
L&J Services LLC |
Limited Liability Company |
6 highland acres rd marshalltown iowa 50158 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-18 |
Josh Colwell |
centraliowa@fibrenew.com |
Marshalltown |
IA |
United States |
Micah Hesse |
Hunter Bolinsger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Colwell |
centraliowa@fibrenew.com |
Owner |
Marshalltown |
IA |
United States |
Micah Hesse |
Hunter Bolsinger |
Signed |
1585 |
2023-04-18 14:04 |
Anonymous (not verified) |
94.188.205.167 |
L&J Services LLC |
Limited Liability Company |
6 highland acres rd marshalltown iowa 50158 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-18 |
Josh Colwell |
centraliowa@fibrenew.com |
Marshalltown |
IA |
United States |
Micah Hesse |
Hunter Bolinsger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Colwell |
centraliowa@fibrenew.com |
Owner |
Marshalltown |
IA |
United States |
Micah Hesse |
Hunter Bolsinger |
Signed |
343 |
2020-12-28 10:46 |
Anonymous (not verified) |
173.18.204.82 |
Shelly Hildebrand |
Proprietorship |
424 E 44th St Pleasant Hill Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-28 |
Shelly Hildebrand |
centraliowacleaningservice@mediacombb.net |
Pleasant Hill |
Polk |
Iowa |
Cathy Stevens |
Bailey Hildebrand |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shelly Hildebrand |
centraliowacleaningservice@mediacombb.net |
Self |
Pleasant Hill |
Polk |
Iowa |
Cathy Stevens |
Bailey Hildebrand |
Signed |
755 |
2021-11-19 13:25 |
Anonymous (not verified) |
65.144.174.26 |
Central Iowa Insulation and Floors Inc |
Proprietorship |
14858 118 Ave, Indianola, IA 50125 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-19 |
Ivan Pilat |
centraliowaif@gmail.com |
Indianola |
Warren |
Iowa |
Mark Kapustin |
Vladimir Orbinan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ivan Pilat |
centraliowaif@gmail.com |
Self |
Indianola |
Warren |
Iowa |
Mark Kapustin |
Vladimir Orbinan |
Signed |
1381 |
2022-11-30 20:41 |
Anonymous (not verified) |
97.125.145.12 |
Central Iowa Outdoor Services |
Proprietorship |
1213 Parkhill Dr. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-30 |
Keegan Eggers |
CentralIowaServices1@gmail.com |
Norwalk |
Iowa |
United States |
Stephanie Eggers |
Kelsie Eggers |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Keegan Eggers |
CentralIowaServices1@gmail.com |
Owner |
Norwalk |
Iowa |
United States |
Stephanie Eggers |
Kelsie Eggers |
Signed |
1950 |
2023-12-12 12:20 |
Anonymous (not verified) |
94.188.205.168 |
Central Iowa Welding & Repair |
Limited Liability Company |
13913 140th Avenue |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-01 |
Trevor Campbell |
centraliowaweldingrepair@gmail.com |
Indianola |
Warren |
Iowa |
Amber Campbell |
Jake Snow |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Trevor Campbell |
centraliowaweldingrepair@gmail.com |
Owner |
Indianola |
Warren |
Iowa |
Amber Campbell |
Jake Snow |
Signed |
1460 |
2023-02-16 12:36 |
Anonymous (not verified) |
94.188.205.174 |
Certified Septic Service |
Proprietorship |
2121 Rodeo ave monroe iowa 50170 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-16 |
Justin Rozendaal |
jusroz12@gmail.com |
Monroe |
Jasper |
Iowa |
Justin Rozendaal |
Miranda Rozendaal |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Rozendaal |
certifiedseptic@gmail.com |
Self |
Monroe |
Jasper |
Iowa |
Justin Rozendaal |
Miranda Rozendaal |
Signed |
1115 |
2022-05-17 19:36 |
Anonymous (not verified) |
173.23.50.204 |
Delgado Electrical Services |
Limited Liability Company |
1210 Creston Ave Des Moines, Iowa 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-17 |
Cesar Delgado |
delgado.electrical@gmail.com |
Des Moines |
Polk |
Iowa |
Mike Willet |
Alex Segovia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cesar Delgado |
cesar.delgado31@yahoo.com |
Owner |
Des Moines |
Polk |
Iowa |
Mike Willet |
Alex Segovia |
Signed |
1252 |
2022-08-12 13:11 |
Anonymous (not verified) |
166.181.85.235 |
Cesar cardenas |
Proprietorship |
48644 roma valley dr |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-06 |
Cesar Octavio Cardenas navarrete |
cesarcardenas981@gmail.com |
Des moines |
Polk |
Iowa |
Cesar cardenas navarrete |
Cesar cardenas Gonzalez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cesar cardenas |
cesarcardenas981@gmail.com |
Myself |
Des moines |
Polk |
Iowa |
Cesar cardenas |
Cesar cardenas gonzalez |
Signed |
916 |
2022-02-16 09:23 |
Anonymous (not verified) |
173.18.22.217 |
Cesar Ponce |
Proprietorship |
150 Aspen Dr. Norwalk 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. |
2022-02-16 |
Cesar Ponce |
cesarponce00@icloud.com |
Nowalk |
Warren |
Iowa |
Lesa Reeves |
Jennifer Lambert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cesar Ponce |
cesarponce00@icloud.com |
Owner |
Norwalk |
Warren |
Iowa |
Lesa Reeves |
Jennifer Lambert |
Signed |
283 |
2020-10-21 09:19 |
Anonymous (not verified) |
192.16.108.199 |
Blazin Homes |
Proprietorship |
2306 Hill St Denison Iowa 51442 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-21 |
Chad David Blasey |
chadblasey@yahoo.com |
Denison |
Crawford |
Iowa |
Amy Hansen |
Todd Stadtlander |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chad David Blasey |
chadblasey@yahoo.com |
Owner |
Dension |
Crawford |
Iowa |
Amy Hansen |
Todd Stadtlander |
Signed |
231 |
2020-08-13 18:22 |
Anonymous (not verified) |
173.27.28.18 |
Kelley Contracting |
Proprietorship |
115 Pinecrest Circle Elk Run Heights, Ia 50707 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-13 |
Chad Kelley |
chadkelley22@gmail.com |
Elk Run Heights |
Black Hawk |
Iowa |
Jack Kelley |
Jennifer Kelley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kelley Contracting |
chadkelley22@gmail.com |
Self |
Elk Run Heights |
Black Hawk |
Iowa |
Jack Kelley |
Jennifer Kelley |
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 |
749 |
2021-11-15 16:05 |
Anonymous (not verified) |
173.31.148.43 |
CHAMONE SWITZER |
Proprietorship |
PO BOX 72 FOSTORIA IA 51340 |
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. |
2021-11-15 |
CHAMONE SWITZER |
CHAMONE.SWITZER@GMAIL.COM |
FOSTORIA |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNG WIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
CHAMONE SWITZER |
CHAMONE.SWITZER@GMAIL.COM |
SELF |
FOSTORIA |
IA |
United States |
TAMI KILEIN |
JENNIFER YOUNGWIRTH |
Signed |
1195 |
2022-07-08 13:24 |
Anonymous (not verified) |
174.198.67.66 |
Chapas Construction |
Limited Liability Company |
6424 Roseland 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. |
2022-07-08 |
Polibio Raul Chapa Farez |
chapasconstructionllc@gmail.com |
Urbandale |
IA |
IA |
Brenda Rivas |
Charlie Chapa |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Polibio Raul Chapa |
chapasconstructionllc@gmail.com |
President |
Urbandale |
IA |
IA |
Brenda Rivas |
Charlie Chapa |
Signed |
696 |
2021-10-28 10:33 |
Anonymous (not verified) |
173.18.85.215 |
Saunders Construction |
Proprietorship |
7304 SW 14th St Des Moines Iowa 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-28 |
Charles A Saunders |
charlessaunders901@gmail.com |
Des Moines |
IA |
United States |
Ramona Mitchell |
Rasheedah Gasaway |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Charles Saunders |
charlessaunders901@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Ramona Mitchell |
Rasheedah Gasaway |
Signed |
701 |
2021-10-29 18:35 |
Anonymous (not verified) |
173.18.85.215 |
Saunders Construction |
Proprietorship |
7304 SW 14th 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. |
2021-10-29 |
Charles Saunders |
charlessaunders901@gmail.com |
Des Moines |
Iowa |
Iowa |
Ramona Mitchell |
Rasheedah Gasaway |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Charles Saunders |
charlessaunders901@gmail.com |
Owner |
Des Moines |
IA |
United States |
Ramona Mitchell |
Rasheedah Gasaway |
Signed |
811 |
2021-12-22 17:31 |
Anonymous (not verified) |
166.181.85.89 |
Demmer Construction |
Proprietorship |
203 Michigan Ave Farley, IA 52046 |
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. |
2021-12-22 |
Charles Demmer |
charliedemmer@gmail.com |
Farley |
Dubuque |
Ia |
Michele Demmer |
Jennifer White |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Charles Demmer |
charliedemmer@gmail.com |
Self |
Farley |
Dubuque |
Ia |
Michele Kay Demmer |
Jennifer Marie White |
Signed |
812 |
2021-12-22 17:31 |
Anonymous (not verified) |
166.181.85.89 |
Demmer Construction |
Proprietorship |
203 Michigan Ave Farley, IA 52046 |
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. |
2021-12-22 |
Charles Demmer |
charliedemmer@gmail.com |
Farley |
Dubuque |
Ia |
Michele Demmer |
Jennifer White |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Charles Demmer |
charliedemmer@gmail.com |
Self |
Farley |
Dubuque |
Ia |
Michele Kay Demmer |
Jennifer Marie White |
Signed |
482 |
2021-04-14 21:21 |
Anonymous (not verified) |
98.17.35.5 |
K3 Recycling LLC |
Limited Liability Company |
14801 180th Ave, Milo, IA 50166 |
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. |
2021-04-14 |
Charles Raymond Kappelman |
charliekappelman@yahoo.com |
MILO |
Warren |
United States |
Ryan Matthew Kappelman |
John Allen Bahr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
K3 Recycling LLC |
charliekappelman@yahoo.com |
Co-owner |
Milo |
Warren |
Iowa |
Ryan Matthew Kappelman |
John Allen Bahr |
Signed |
1909 |
2023-11-15 12:27 |
Anonymous (not verified) |
94.188.207.228 |
CHAR-LES BUILDINGS LLC |
Limited Liability Company |
14633 7TH AVE NW, ANDOVER MN 55304 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-15 |
JOHNNY CHAVEZ CHAVEZ |
charlychavez151@gmail.com |
ANDOVER |
ANOKA |
MINNESOTA |
ALEIDA LEE |
DANY JIMBO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JOHNNY CHAVEZ CHAVEZ |
charlychavez151@gmail.com |
OWNER |
ANDOVER |
ANOKA |
MINNESOTA |
ALEIDA LEE |
DANY JIMBO |
Signed |
2137 |
2024-04-05 10:28 |
Anonymous (not verified) |
94.188.207.227 |
Innovationsgenc@gmail.com |
Limited Liability Company |
1134 20th Avenue |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-05 |
Juan carlos Soto Deanda |
charlye2512penelope@gmail.com |
East Moline |
IL |
United States |
Deja Rivers |
Eric Schwab |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Juan carlos Soto Deanda |
charlye2512penelope@gmail.com |
Owner |
East Moline |
IL |
United States |
Deja Rivers |
Eric Schwab |
Signed |
1694 |
2023-06-16 14:37 |
Anonymous (not verified) |
94.188.205.176 |
Leaf Home Solutions LLC |
Partnership |
3060 SE Grimes Blvd Suite 100-300, Grimes, IA 50111 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-16 |
Caleb Brincks |
chbrincks@gmail.com |
628 NE 56th St Ankeny IA, 50021 |
Polk County |
Iowa |
Melissa Brincks |
Anisha Moten |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
AFTON INC |
chbrincks@gmail.com |
Owner |
Ankeny |
Polk |
Iowa |
Melissa Brincks |
Anisha Moten |
Signed |
380 |
2021-02-01 15:04 |
Anonymous (not verified) |
192.30.185.142 |
Chelos Framing Crew |
Proprietorship |
501 Colon Street, Sioux City, IA 51503 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-01 |
Marcelo Lopez |
chelosframingcrew@icloud.com |
Sioux City |
Woodbury |
IA |
Katie Jenks |
Virginia Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marcelo Lopez |
chelosframingcrew@icloud.com |
Owner |
Sioux City |
Woodbury |
IA |
Katie Jenks |
Virginia Anderson |
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 |
102 |
2020-03-25 11:23 |
Anonymous (not verified) |
206.72.14.249 |
Brandi Wehr |
Proprietorship |
123 E Marion St, Sigourney, IA 52591 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-25 |
Brandi Jo Wehr |
brndwehr54@hotmail.com |
Sigourney |
Keokuk |
Iowa |
Amber Kephart |
Mary Beth Knipfer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chelsea Voss |
chelsea@grimmrealestate.com |
Agent |
North English |
Iowa |
Iowa |
Amber Kephart |
Mary Beth Knipfer |
Signed |
487 |
2021-04-20 11:10 |
Anonymous (not verified) |
207.191.193.167 |
Chento Construction |
Proprietorship |
702 Lincoln St. Ainsworth, IA 52201 |
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. |
2021-04-05 |
Alberto Garcia |
chentoconstruction@hotmail.com |
Ainsworth |
Washington |
Iowa |
Anthony Johnson |
Jessica Lopez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alberto Garcia |
chentoconstruction@hotmail.com |
Owner |
Ainsworth |
Washington |
Iowa |
Anthony Johnson |
Jessica Lopez |
Signed |
1101 |
2022-05-13 12:55 |
Anonymous (not verified) |
174.199.102.54 |
Daniel Blanco |
Proprietorship |
1403 2nd 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. |
2022-05-13 |
Daniel Blanco |
chindan77@yahoo.com |
Ft Dodge |
Webster |
IA |
Vanessa Blanco |
Elva Castañeda |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Blanco |
chindan77@yahoo.com |
Self |
Ft Dodge |
Webster |
IA |
Vanessa Blanco |
Elva Castañeda |
Signed |
1900 |
2023-11-09 23:24 |
Anonymous (not verified) |
94.188.207.224 |
Daniel Blanco |
Proprietorship |
1403 2nd 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. |
2023-11-09 |
Daniel Blanco |
chindan77@yahoo.com |
Fort Dodge |
IA |
United States |
Vanessa Blanco |
Jorge Blanco |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Blanco |
chindan77@yahoo.com |
Self |
Fort Dodge |
IA |
United States |
Elva Castañeda |
Vanessa Blanco |
Signed |
245 |
2020-08-25 15:20 |
Anonymous (not verified) |
107.77.207.111 |
J&R cleaning co LLC |
Limited Liability Company |
14300 Holcomb ave #210 urbandale ia. 50323 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-25 |
José A salas romero |
chinito80sr@hotmail.com |
Desmoines |
Polk |
Iowa |
Ana López |
Jesus gonzales |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
José romero |
chinito80sr@hotmail.com |
Owner |
Desmoines |
Polk |
Iowa |
Ana lopez |
Jesus Gonzales |
Signed |