1698 |
2023-06-20 16:43 |
Anonymous (not verified) |
94.188.205.167 |
Mike farrell |
Proprietorship |
306 ne trilein dr ankeny,ia 50021 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-20 |
Michael David farrell |
farrellsfmr@yahoo.com |
Ankeny |
Polk |
Ia |
ERICK SCHULST |
Kelly Coluzzi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael David farrell |
farrellsfmr@yahoo.com |
Owner |
Ankeny |
Polk |
Iowa |
Erick Schuldr |
Kelly .Coluzzi3 |
Signed |
1438 |
2023-02-03 14:23 |
Anonymous (not verified) |
173.18.22.217 |
Cruz Construction Company, LLC |
Proprietorship |
2105 Clark 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. |
2023-02-03 |
Juan Canseco Cruz |
jcruz2515@icloud.com |
Des Moines |
Polk |
Iowa |
Erick Schuldt |
Kelly Coluzzi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Juan Conseco Cruz |
jcruz2515@icloud.com |
Owner |
Des Moines |
Polk |
Iowa |
Erick Schuldt |
Kelly Coluzzi |
Signed |
163 |
2020-05-20 11:58 |
Anonymous (not verified) |
173.27.1.111 |
David |
Proprietorship |
4023 E 28th st 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-20 |
David Ortiz |
jdiconstrucction@gmail.com |
Des Moines |
Polk County |
Iowa |
Erika Olague |
Jieldh Ortiz-Olague |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Ortiz |
jdiconstrucction@gmail.com |
JDI Construction |
Des Moines |
Polk County |
Iowa |
Erika Olague |
Jieldh Ortiz-Olague |
Signed |
1728 |
2023-07-08 10:48 |
Anonymous (not verified) |
94.188.207.230 |
Lima Charlie LLC |
Limited Liability Company |
56066 257th Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-10 |
Larry Homan |
larry@Lima-Charlie.biz |
Glenwood |
Iowa |
United States |
Erin Jenkins |
Jeremy Jenkins |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Larry Lee Homan |
Larry@Lima-Charlie.biz |
Owner |
Glenwood |
Iowa |
United States |
Erin Homan |
Jeremy Jenkins |
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 |
1169 |
2022-06-23 16:23 |
Anonymous (not verified) |
159.45.71.17 |
Whitlow Remodeling and Home Services, LLC |
Limited Liability Company |
6421 NW 54th Ct Johnston Iowa 50131 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-23 |
Scot Alan Whitlow |
resaw375@msn.com |
Johnston |
Polk |
Iowa |
Erin Scanlan |
Charles Thorn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Scot Alan Whitlow |
resaw375@msn.com |
Owner |
Johnston |
Polk |
Iowa |
Erin Scanlan |
Charles Thorn |
Signed |
1146 |
2022-06-07 11:51 |
Anonymous (not verified) |
173.27.226.177 |
Evans Endeavors LLC |
Limited Liability Company |
513 N Roche 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. |
2022-06-07 |
Cody Evans |
evansendeavor@gmail.com |
Knoxville |
Marion |
Iowa |
Erin Six |
Carl stoffer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cody Evans |
evansendeavor@gmail.com |
Myself |
Knoxville |
Marion |
Iowa |
Erin six |
Carl Stoffer |
Signed |
1157 |
2022-06-16 07:56 |
Anonymous (not verified) |
97.125.185.191 |
Apex Remodeling |
Proprietorship |
709 w. North 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. |
2022-06-15 |
Nick Winters |
nick.winters@apex-roofing.com |
WINTERSET |
Iowa |
Iowa |
Erin Winters |
Rob Tennat |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nick Winters |
nick.winters@apex-roofing.com |
Owner |
WINTERSET |
Iowa |
Iowa |
Erin Winters |
Rob Tennat |
Signed |
929 |
2022-02-18 09:18 |
Anonymous (not verified) |
174.198.74.217 |
LA Painting LLC |
Limited Liability Company |
6460 Merle Hay Rd unit 222 Johnston, IA 50131 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-18 |
Adolfo Rodriguez Afanador |
adolforodriguez11@yahoo.com |
Johnston |
Polk |
Iowa |
Esequiel Rodriguez |
Karina Valdez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adolfo Rodriguez Afanador |
adolforodriguez11@yahoo.com |
Owner |
Johnston |
Polk |
Iowa |
Esequiel Rodriguez |
Karina Valdez |
Signed |
179 |
2020-06-09 11:22 |
Anonymous (not verified) |
173.31.147.225 |
SAUL GUERARA MEZA |
Proprietorship |
26 WESTVIEW DRIVE APT 5 MILFORD IA 51351 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-21 |
SAUL GUERARA MEZA |
ESMEJ2513@GMAIL.COM |
MILFORD |
DICKINSON |
IOWA |
ESMIRALDO JIMENEZ |
TAMI KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SAUL GUERARA MEZA |
ESMEJ2513@GMAIL.COM |
SELF |
MILFORD |
DICKINSON |
IOWA |
ESMIRALDO JIMENEZ |
TAMI KLEIN |
Signed |
1544 |
2023-03-29 16:52 |
Anonymous (not verified) |
94.188.207.228 |
Live Wire Trucking |
Limited Liability Company |
109 E Marion Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-29 |
Joshua Allen Moore |
livewiretruckingIA@gmail.com |
Sigourney |
Iowa |
United States |
Ethan Weber |
Dylan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua Allen Moore |
livewiretruckingIA@gmail.com |
Owner |
Sigourney |
Iowa |
United States |
Ethan David Weber |
Dylan Jefferey Miller |
Signed |
1291 |
2022-09-02 13:24 |
Anonymous (not verified) |
173.20.146.6 |
Nicci Keck LLC |
Limited Liability Company |
1107 Pheasant Valley St, Iowa City, IA 52246 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-02 |
Nicole Keck |
niccikeckllc@gmail.com |
Iowa City |
Iowa |
United States |
Evangeline Kadera |
Denise Kandel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicole Keck |
niccikeckllc@gmail.com |
Managing Member/Owner/President |
Iowa City |
Johnson |
Iowa |
Evangeline Kadera |
Denise Kandel |
Signed |
1292 |
2022-09-02 13:26 |
Anonymous (not verified) |
173.20.146.6 |
Nicci Keck LLC |
Limited Liability Company |
1107 Pheasant Valley St, Iowa City, IA 52246 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-02 |
Benjamin Darbro |
darbrob@gmail.com |
Iowa City |
Iowa |
United States |
Evangeline Kadera |
Denise Kandel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicole Keck |
niccikeckllc@gmail.com |
Managing Member/Owner/President |
Iowa City |
Johnson |
Iowa |
Evangeline Kadera |
Denise Kandel |
Signed |
1708 |
2023-06-25 15:10 |
Anonymous (not verified) |
94.188.207.228 |
Lopez concrete |
Limited Liability Company |
2009 otley ave 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. |
2023-06-25 |
Erick Lopez |
lopez1concrete@gmail.com |
Perry |
Dallas |
IA |
Ever tobar. |
Elba alejandro |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Erick lopez |
lopez1concreto@gmail.com |
Owner |
Perry |
Dallas |
IA |
Ever tobar |
Elba alejandro |
Signed |
2068 |
2024-03-01 09:53 |
Anonymous (not verified) |
94.188.207.226 |
A-1 Stone LLC |
Limited Liability Company |
4308 Boyd St Des Moines IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-01 |
Orlando Nunez |
nunezstone@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Perla Patricia Nunez |
nunezstone@gmail.com |
Employee |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2069 |
2024-03-01 09:55 |
Anonymous (not verified) |
94.188.207.226 |
A-1 Stone LLC |
Limited Liability Company |
4308 Boyd St Des Moines IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-01 |
Orlando Manuel Nunez Mejia |
orlando20025@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Perla Patricia Nunez |
nunezstone@gmail.com |
Employee |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2124 |
2024-03-28 13:47 |
Anonymous (not verified) |
94.188.207.225 |
Gudiel Construction & Masonry LLC |
Limited Liability Company |
303 Lacona Ave Des Moines Iowa 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-28 |
Santiago Gudiel Lopez |
gudielsantiago972@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Santiago Gudiel Lpez |
gudielsantiago972@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2129 |
2024-04-01 14:16 |
Anonymous (not verified) |
94.188.207.227 |
Des Moines Construction LLC |
Limited Liability Company |
6615 SE 3rd St Des Moines IA 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-01 |
Rodrigo Valdes |
desmoinesconstructionllc@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rodrigo Valdes |
desmoinesconstructionllc@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2130 |
2024-04-02 09:11 |
Anonymous (not verified) |
94.188.207.229 |
Caliz Stone Services LLC |
Limited Liability Company |
1715 E 21st St, Des Moines IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-02 |
Marvin Lopez |
marvincaliz843@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marvin Lopez |
marvincaliz843@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2136 |
2024-04-04 16:08 |
Anonymous (not verified) |
94.188.205.169 |
Elite Construction & Masonry LLC |
Limited Liability Company |
3309 Wright St Des Moines IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-04 |
Manuel Mejia |
eliteconstructionmasonryllc@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Manuel Mejia |
eliteconstructionmasonryllc@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2187 |
2024-04-29 08:30 |
Anonymous (not verified) |
94.188.207.226 |
Fran Stonework LLC |
Limited Liability Company |
1222 E Seneca Ave Apt 7, Des Moines, IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-29 |
Francisco Rodriguez Rios |
panchito941@icloud.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Francisco Rodriguez Rios |
panchito941@icloud.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2189 |
2024-04-29 09:23 |
Anonymous (not verified) |
94.188.207.225 |
Sals Home Improvements LLC |
Limited Liability Company |
3750 NW Maple Ct Ankeny IA 50023 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-29 |
Salvador Gomez |
salvadorg27@hotmail.com |
Ankeny |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Salvador Gomez |
salvadorg27@hotmail.com |
Self |
Ankeny |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2196 |
2024-05-01 09:18 |
Anonymous (not verified) |
94.188.207.230 |
Penaloza Stone LLC |
Limited Liability Company |
1530 8th St Des Moines IA 50314 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-01 |
Javier Marcial Penaloza |
javiermarcial.jmp@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Javier Marcial Penaloza |
javiermarcial.jmp@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2197 |
2024-05-02 09:30 |
Anonymous (not verified) |
94.188.207.229 |
Melvin Osorio |
Proprietorship |
3848 E 14th St Trlr 78, Des Moines IA 50313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-02 |
Melvin Osorio |
matamorosana56@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melvin Osorio |
matamorosana56@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2198 |
2024-05-02 11:26 |
Anonymous (not verified) |
94.188.207.224 |
Sierra Stone LLC |
Limited Liability Company |
2504 E 37th St Des Moines IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-02 |
Daniel Nunez |
danieln2024@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Nunez |
danieln2024@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2039 |
2024-02-08 09:25 |
Anonymous (not verified) |
94.188.207.229 |
Home Re Construction, LLC |
Limited Liability Company |
5285 NE Mitchell Drive, Mitchellville, IA 50169 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-08 |
Francisco Miguel Palomares Velasco |
homereconstruction@hotmail.com |
Mitchellville |
Polk |
Iowa |
Fabiola Palomares Recendiz |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Francisco Miguel Palomares Velasco |
homereconstruction@hotmail.com |
Self |
Mithcellville |
Polk |
Iowa |
Fabiola Palomares Recendiz |
Nathan Miller |
Signed |
2118 |
2024-03-27 13:25 |
Anonymous (not verified) |
94.188.207.223 |
Zaragoza Home Solutions LLC |
Limited Liability Company |
1644 E Walnut St. Des Moines IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-27 |
Roberto C. Curiel |
zaragozahomesolutionsllc@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares Recendiz |
Francisco A Palomares Zepeda |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Roberto C Curiel |
zaragozahomesolutionsllc@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares Recendiz |
Francisco A Palomares Zepeda |
Signed |
1393 |
2022-12-13 12:45 |
Anonymous (not verified) |
50.82.133.22 |
Ponderosa Outdoor |
Limited Liability Partnership |
104 Vista Dr Montezuma, Ia 50171 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-12-13 |
Daniel Deaver |
ponderosaoutdoor@gmail.com |
Altoona |
Polk |
Iowa |
Faith Deaver |
Jessi Perkins |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Deaver |
ponderosaoutdoor@gmail.com |
self |
Altoona |
Polk |
Iowa |
Faith Deaver |
Jessi Perkins |
Signed |
94 |
2020-03-18 13:18 |
Anonymous (not verified) |
174.243.114.80 |
Sogard Excavating |
Limited Liability Company |
2374 380th St, Jewell, IA 50130 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-18 |
Jon A Sogard |
jsogard22@gmail.com |
Jewell |
Hamilton |
IA |
Fallon Sogard |
Julee Lund |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sogard Excavating LLC |
jsogard22@gmail.com |
owner |
Jewell |
Hamilton |
IA |
Fallon Sogard |
Julee Lund |
Signed |
509 |
2021-05-10 15:25 |
Anonymous (not verified) |
108.190.5.14 |
Shift Transport LLC |
Limited Liability Company |
4215 Kris Line Drive Waterloo, IA 50701 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-10 |
Damir Pajazetovic |
damirp2015@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Fata Pajazetovic |
Melda Pajazetovic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adnan Pajazetovic |
adoni.shift@gmail.com |
Owner |
Waterloo |
Black Hawk |
Iowa |
Fata Pajazetovic |
Melda Pajazetovic |
Signed |
510 |
2021-05-10 15:27 |
Anonymous (not verified) |
108.190.5.14 |
Shift Transport LLC |
Limited Liability Company |
4215 Kris Line 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. |
2021-05-10 |
Adnan Pajazetovic |
Adoni.shift@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Fata Pajazetovic |
Melda Pajazetovic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adnan Pajazetovic |
adoni.shift@gmail.com |
Owner |
Waterloo |
Black Hawk |
Iowa |
Fata Pajazetovic |
Melda Pajazetovic |
Signed |
1409 |
2023-01-05 11:55 |
Anonymous (not verified) |
173.23.88.7 |
Top tier gutter systems llc |
Limited Liability Company |
405a 1st Ave sw Cedar Rapids, 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. |
2023-01-05 |
Rocky layne smith |
toptierguttersystems@yahoo.com |
Cedar Rapids |
Linn |
IA |
Faye momodu |
Rocky smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rocky smith |
toptierguttersystems@yahoo.com |
Self |
Cedar Rapids |
Linn |
IA |
Faye momodu |
Derrick |
Signed |
1074 |
2022-04-27 12:16 |
Anonymous (not verified) |
66.129.216.227 |
Kristyn M Gerst Counseling LLC |
Limited Liability Company |
30 Villager Dr. Apt. 3 North Liberty, IA 52317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-27 |
Kristyn May Gerst |
kmwatson18@gmail.com |
North Liberty |
johnson |
Iowa |
Forrest John Gerst |
Heather Lynn Watson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kristyn May Gerst |
kmwatson18@gmail.com |
self |
North Liberty |
Johnson |
Iowa |
Forrest John Gerst |
Heather Lynn Watson |
Signed |
711 |
2021-11-04 13:07 |
Anonymous (not verified) |
174.216.69.18 |
Corey Gramowski |
Proprietorship |
2101 21st ST Emmetsburg IA 50536 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-04 |
Corey Gramowski |
gramowski@windstream.net |
Emmetsburg |
Palo Alto |
IA |
Frank Kliegl |
John Heddinger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Corey Gramowski |
gramowski@windstream.net |
Self |
Emmetsburg |
Palo Alto |
IA |
Frank Kliegl |
John Heddinger |
Signed |
21 |
2020-01-01 18:16 |
Anonymous (not verified) |
72.35.186.80 |
Jerry Arnold |
Proprietorship |
1426 25th St, Humeston, IA 50123 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-01 |
Jerry Arnold |
LLArnold62@gmail.com |
Humeston |
Wayne |
Iowa |
Fred Throckmorton |
Joyce Throckmorton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jerry Arnold |
LLArnold62@gmail.com |
Self |
Humeston |
Wayne |
Iowa |
Fred Throckmorton |
Joyce Throckmorton |
Signed |
638 |
2021-09-13 09:18 |
Anonymous (not verified) |
74.84.91.178 |
Thomas Tremble |
Proprietorship |
1209 University Avenue, Dubuque, IA 52001 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-09 |
Thomas Tremble |
TJTremble21@gmail.com |
Dubuque |
Dubuque |
Iowa |
Gabe Drewelow |
Derrick Parsons |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Thomas Tremble |
TJTremble21@gmail.com |
self |
Dubuque |
Dubuque |
Iowa |
Gabe Drewelow |
Derrick Parsons |
Signed |
220 |
2020-08-02 13:45 |
Anonymous (not verified) |
99.203.112.113 |
R&G SEAMLESS GUTTERS |
Proprietorship |
3244 Dubuque Ave, 3244 Dubuque Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-02 |
Ruben Munoz Haro |
munozharoruben@gmail.com |
Des Moines |
Polk |
Estados Unidos |
Gabriel Ramirez |
Adriana Ramirez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ruben Munoz- R&G SEAMLESS GUTTERS |
Munozharoruben@gmail.com |
owner |
3244 Dubuque Ave Des Moines Iowa 50317 |
polk |
iowa |
Gabriel Ramirez |
Adriana Ramirez |
Signed |
443 |
2021-03-22 13:22 |
Anonymous (not verified) |
167.127.218.244 |
Romero Carpentry |
Proprietorship |
2060 King Ave, Apt 19, Des Moines, IA 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-22 |
Jose Wilber Romero Batres |
Josew.batres@icloud.com |
Des moines |
Polk |
United States |
Gabriela Cecibel Chicas |
David Antonio Barrera Serrano |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Wilber Romero Batres |
Josew.batres@icloud.com |
Self |
Des Moines |
Polk |
Iowa |
Gabriela Cecibel Chicas |
David Antonio Barrera Serrano |
Signed |
1552 |
2023-04-03 13:58 |
Anonymous (not verified) |
94.188.205.168 |
F&I Drywall Llc |
Limited Liability Company |
509 Arlington 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. |
2023-04-03 |
Fernando Garcia |
Fgarcia1989.fg@gmail.com |
Marshalltown |
Marshall |
Iowa |
Gabriela Garcia |
Araceli Tafolla |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Fernando Garcia |
Fgarcia1989.fg@gmail.com |
Self |
Marshalltown |
Marshall |
Iowa |
Gabriela Garcia |
Araceli Tafolla |
Signed |
1981 |
2024-01-10 22:12 |
Anonymous (not verified) |
94.188.205.175 |
Level Up Renovations LLC |
Limited Liability Company |
648 31st Street, Des Moines, IA 50312 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-10 |
Luis Humberto Cazares Lopez |
leveluprenovationsia@outlook.com |
Des Moines |
Polk |
Iowa |
Gabriela Joanne Cazares |
Raquel Medina |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luis Humberto Cazares Lopez |
leveluprenovationsia@outlook.com |
Owner |
Des Moines |
Polk |
Iowa |
Gabriela Joanne Cazares |
Raquel Medina |
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 |
1264 |
2022-08-16 21:22 |
Anonymous (not verified) |
50.82.84.19 |
Nogotta Trucking LLC |
Limited Liability Company |
16617 Wilden Dr, 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. |
2022-08-16 |
Adam Dickinson |
nogottatruckingllc@gmail.com |
Clive |
IA |
United States |
Gary Dickinson |
Mike Martens |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adam Dickinson |
nogottatruckingllc@gmail.com |
Managing Member |
Clive |
IA |
United States |
Gary Dickinson |
Mike Martens |
Signed |
2103 |
2024-03-18 12:33 |
Anonymous (not verified) |
94.188.205.177 |
Scornos 1973 Inc |
Proprietorship |
8561 hickman rd urbandale iowa 50322 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-18 |
Liana Fatino |
lfatino@yahoo.com |
des moines |
POLK |
IOWA |
GARY FATINO |
LISA VACCO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
GARY FATINO |
lfatino@yahoo.com |
husband |
des moines |
polk |
iowa |
Gary Fatino |
Lisa Vacco |
Signed |
2105 |
2024-03-18 12:45 |
Anonymous (not verified) |
94.188.205.169 |
Scornos Altoona LLC |
Proprietorship |
2437 adventureland dr altoona iowaa 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. |
2024-03-18 |
Liana Fatino |
lfatino@yahoo.com |
des moines |
POLK |
IOWA |
GARY FATINO |
LISA VACCO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
GARY FATINO |
lfatino@yahoo.com |
husband |
des moines |
polk |
iowa |
Gary Fatino |
Lisa Vacco |
Signed |
286 |
2020-10-21 18:32 |
Anonymous (not verified) |
173.218.73.44 |
Bilyeu Underground LLC |
Limited Liability Company |
1136 W. Irene Ct. Nixa, MO 65714 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Daniel Bilyeu |
danielbilyeu@gmail.com |
Nixa |
Christian |
Missouri |
Gary George Bilyeu |
Chad Anthony Charles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Bilyeu |
danielbilyeu@gmail.com |
Owner |
Nixa |
Christian |
Missouri |
Gary George Bilyeu |
Chad Anthony Charles |
Signed |
288 |
2020-10-21 18:36 |
Anonymous (not verified) |
173.218.73.44 |
Bilyeu Underground LLC |
Limited Liability Company |
1136 W. Irene Ct. Nixa, MO 65714 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Anthony Charles |
y4ardgn0m3r@gmail.com |
Nixa |
Christian |
Missouri |
Gary George Bilyeu |
Daniel Bilyeu |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chad Anthony Charles |
y4ardgn0m3r@gmail.com |
Owner |
Nixa |
Christian |
Missouri |
Gary George Bilyeu |
Daniel Bilyeu |
Signed |
117 |
2020-04-11 09:08 |
Anonymous (not verified) |
72.255.83.134 |
MIDWEST AG SOLUTIONS, LLC |
Limited Liability Company |
4949 PLEASANT ST, STE 204, WEST DES MOINES, IA 50266 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-11 |
DALE A EASTMAN |
dale@emdsm.com |
Waukee |
Dallas |
IA |
Gary Marshall |
Brittain Bachus |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
DALE A EASTMAN |
dale@emdsm.com |
same |
WAUKEE |
DALLAS |
IA |
GARY MARSHALL |
BRITTAIN BACHUS |
Signed |
983 |
2022-03-18 11:02 |
Anonymous (not verified) |
66.180.9.84 |
Gary Runyon |
Proprietorship |
101 Harris St Ste 1 Hastings, IA 51540 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-18 |
Gary Runyon |
garyrunyon26@gmail.com |
Henderson |
Mills |
Iowa |
Gary Runyon |
Cathy Mardesen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gary Runyon |
garyrunyon26@gmail.com |
owner |
Henderson |
Mills |
Iowa |
Gary Runyon |
Cathy Mardesen |
Signed |
2153 |
2024-04-15 21:59 |
Anonymous (not verified) |
94.188.205.167 |
Ethan M Hoffman |
Proprietorship |
1442 N. County RD 800, Hamilton, IL 62341 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-07 |
Ethan M Hoffman |
kellylanz1967@gmail.com |
Hamilton |
IL |
United States |
Gay Hoffman |
Debra Kelley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ethan M Hoffman |
kellylanz1967@gmail.com |
Self |
Hamilton |
IL |
United States |
Gay Hoffman |
Debra Kelley |
Signed |
1721 |
2023-07-06 08:19 |
Anonymous (not verified) |
94.188.207.228 |
Bradford Alexander Carr |
Proprietorship |
3349 Southgate Ct SW Ste 101 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-06 |
Bradford Alexander Carr |
alex.carr@thrivent.com |
Coralville |
Johnson |
Iowa |
Gaylon Heetland |
David King |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bradford Alexander Carr |
alex.carr@thrivent.com |
Self |
Coralville |
Johnson |
Iowa |
Gaylon Heetland |
David King |
Signed |
150 |
2020-05-06 10:59 |
Anonymous (not verified) |
76.190.229.163 |
RNR Holdings LLC |
Limited Liability Company |
4330 Winter Eagle Trail SE Apt B, Iowa City, Iowa 52240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-06 |
Richard E. White |
rwhite245@yahoo.com |
Hermitage |
Mercer |
Pennsylvania |
Gene Bell |
Victor J Veltri |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Richard E White |
rwhite245@yahoo.com |
Owner |
Hermitage |
Mercer |
Pennsylvania |
Gene Bell |
Victor J Veltri |
Signed |
414 |
2021-02-28 15:32 |
Anonymous (not verified) |
174.198.75.211 |
Charlie Christian Hutt |
Proprietorship |
609 E. main St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-29 |
Charlie Christian Hutt |
bmxican_04@hotmail.com |
Brooklyn |
poweshiek |
IA |
gene shafbough |
hannah hutt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Charlie Christian Hutt |
bmxican_04@hotmail.com |
sole |
Brooklyn |
poweshiek |
IA |
gene shafbough |
hannah hutt |
Signed |
1532 |
2023-03-24 18:05 |
Anonymous (not verified) |
94.188.205.174 |
Crafty Dome LLC |
Limited Liability Company |
3524 Stonebridge Rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-24 |
Susan Bernau |
craftydome@yahoo.com |
West Des Moines |
Polk |
Iowa |
George Cummins |
Linda Green |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Susan Bernau |
craftydome@yahoo.com |
owner |
3524 Stonebridge Rd |
Polk |
Iowa |
George Cummins |
Linda Green |
Signed |
1175 |
2022-07-05 07:56 |
Anonymous (not verified) |
64.251.168.116 |
Daniel Alan Valburg |
Proprietorship |
27656 SD Hwy 44 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-05 |
Dan A Valburg |
agflyer620@gwtc.net |
White River |
Mellette |
SD |
George Ludvic |
Julie Ludvik |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Alan Valburg |
agflyer620@gwtc.net |
proprieter |
White River |
mellette |
SD |
George Ludvik |
Julie Ludvik |
Signed |
1176 |
2022-07-05 08:08 |
Anonymous (not verified) |
64.251.168.116 |
Lucky Dude |
Proprietorship |
27656 SD Hwy 44 WHITE RIVER SD 57579 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-05 |
Lucky Dude |
agflyer620@gwtc.net |
White River |
Mellette |
SD |
George Ludvik |
Julie Ludvik |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lucky Dude |
agflyer620@gwtc.net |
proprietor |
White River |
mellette |
SD |
George Ludvik |
Julie Ludvik |
Signed |
581 |
2021-07-22 14:29 |
Anonymous (not verified) |
205.221.255.62 |
MartinHumphrey |
Limited Liability Company |
Cummins Rd. Apt 202 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-22 |
Martin Luverne Humphrey Jr. |
martinhumphreu@gmail.com |
Des Moines |
Polk |
Ioea |
George Porter |
Gerald Lund |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Martin Luverne Humphrey Jr |
martinhumphreu@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
George Porter |
Gerald Lund |
Signed |
118 |
2020-04-13 11:48 |
Anonymous (not verified) |
173.26.152.222 |
Society of St. Vincent de Paul, District Council of Waterloo Iowa,Inc |
Limited Liability Company |
320 Broadway St PO Box 2727 Waterloo IA 50704 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-14 |
Joseph D. Sobczyk |
joczyk@aol.com |
Cedar Falls |
Black Hawk |
Iowa |
George W. Karnick |
Glynis R. Worthington |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joseph D. Sobczyk |
joczyk@aol.com |
self |
Cedar Falls |
Black Hawk |
Iowa |
George W. Karnick |
Glynis R. Worthington |
Signed |
121 |
2020-04-14 15:11 |
Anonymous (not verified) |
173.31.176.75 |
Society of St. Vincent de Paul, District council of Waterloo Iowa,Inc |
Limited Liability Company |
320 Broadway St PO Box 2727 Waterloo IA 50704 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-14 |
Michele E Collison |
darmstad48@aol.com |
Denver |
Bremer |
Iowa |
George W. Karnick |
Glynis R. Worthington |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joseph D. Sobczyk |
joczyk@aol.com |
Secretary of the St. Vincent de Paul District Council of Waterloo, Iowa, Inc. |
Denver |
Bremer |
Iowa |
George W. Karnick |
Glynis R. Worthington |
Signed |
1689 |
2023-06-13 19:55 |
Anonymous (not verified) |
94.188.207.227 |
Gerardo Reyes-Lopez |
Limited Liability Company |
908 West 1st Street, Waterloo, IA ,50701 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-13 |
Gerardo Reyes-lopez |
greyeslopez9@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Guillermina Lopez |
Bernardo Reyes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Denise Seitsinger |
denise@harmsinsuranceagency.com |
Insurance Agent |
Sumner |
Bremer |
Iowa |
Gerardo Reyes |
Bernardo Reyes |
Signed |
1690 |
2023-06-13 20:01 |
Anonymous (not verified) |
94.188.207.227 |
Gerardo Reyes-Lopez |
Limited Liability Company |
908 West 1st Street, Waterloo, Iowa, 50701 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-13 |
Gerardo Reyes-lopez |
bernardo@reyesconstruct.com |
Waterloo |
IA |
United States |
Guillermina Lopez |
Bernardo Reyes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Denise Seitsinger |
denise@harmsinsuranceagency.com |
Insurance Agent |
Sumner |
Bremer |
Iowa |
Gerardo Reyes |
Bernardo Reyes |
Signed |
1155 |
2022-06-14 12:44 |
Anonymous (not verified) |
207.45.82.36 |
GREEN AND SHINE SERVICES INC |
Proprietorship |
210 Ne 41st st Apt 203 Ankeny, IA, 50021 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-14 |
ALEX A. LOPEZ REDONDO |
greenandshineservices@gmail.com |
ankeny |
polk |
iowa |
Giselle roa |
Marta casado |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alex A Lopez Redondo |
greenandshineservices@gmail.com |
propery |
ankeny |
polk |
iowa |
Giselle Roa |
Marta Casado |
Signed |
1435 |
2023-01-31 14:33 |
Anonymous (not verified) |
174.215.242.112 |
Premier builders |
Proprietorship |
1821 East Ridgeway |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Edward Koch |
etkdbq@aol.com |
Waterloo |
IA |
United States |
Glenda mclarty |
Coen Koch |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Edward Koch |
etkdbq@aol.com |
Owner |
Waterloo |
IA |
United States |
Glenda Mclarty |
Coen Koch |
Signed |
1132 |
2022-05-28 12:01 |
Anonymous (not verified) |
166.181.81.175 |
Kamp Trucking LLC |
Limited Liability Company |
3411 doris 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. |
2022-05-28 |
Joseph Michael Kamp |
boss4z9@yahoo.com |
waterloo |
Iowa |
United States |
Glenn Harrison Bearbower |
April Ann Bearbower |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joseph Michael Kamp |
boss4z9@yahoo.com |
same person. I am an owner operator |
waterloo |
Iowa |
United States |
Glenn Harrison Bearbower |
April Ann Bearbower |
Signed |
72 |
2020-02-21 09:43 |
Anonymous (not verified) |
98.18.174.183 |
Forrest E. Whitford DVM LLC |
Limited Liability Company |
P.O. Box 120 - 507 Washington Street, Volga, IA 52077 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Forrest E. Whitford, DVM LLC |
gfw54@hotmail.com |
Volga, IA |
Clayton |
Iowa |
Glenna Whitford |
Pam Vaske |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Forrest E. Whitford, DVM LLC |
gfw54@hotmail.com |
self |
Volga |
Clayton |
Iowa |
Glenna Whitford |
Pam Vaske |
Signed |
1910 |
2023-11-15 13:06 |
Anonymous (not verified) |
94.188.207.228 |
RODRIGUEZ ENTERPRISES III INC |
Limited Liability Company |
905 W US HIGHWAY 30 CARROLL IA 51401 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-14 |
MAURO RODRIGUEZ |
mauro15o1@hotmail.com |
CARROLL |
CARROLL |
IOWA |
GONZALO MUNOZ |
SILVIA CHAVEZ |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MAURO RODRIGUEZ |
mauro15o1@hotmail.com |
OWNER |
CARROLL |
CARROLL |
IA |
GONZALO MUNOZ |
SILVIA CHAVEZ |
Signed |
213 |
2020-07-21 17:47 |
Anonymous (not verified) |
107.77.206.41 |
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 |
Mary Kate friess |
mkfriess71@gmail.com |
Fond du lac |
Fond du lac |
WI |
Gordon Lewis |
Ron carpenter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mary Kate friess |
mkfriess71@gmail.com |
Self |
Fond du lac |
Fond du lac |
Wi |
Gordon Lewis |
Ron carpenter |
Signed |
1982 |
2024-01-11 12:29 |
Anonymous (not verified) |
94.188.205.166 |
Grace Justine |
Proprietorship |
405 Northview 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. |
2024-01-11 |
Grace Justine Wandera / Independent Contractor |
justine.wandera@candeoiowa.org |
Waukee |
IA |
IA |
Grace Justine Wandera / Independent Contractor |
Grace Justine Wandera / Independent Contractor |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Grace Justine Wandera / Independent Contractor |
justine.wandera@candeoiowa.org |
own |
Waukee |
IA |
IA |
Grace Justine Wandera / Independent Contractor |
Grace Justine Wandera / Independent Contractor |
Signed |
1590 |
2023-04-21 07:10 |
Anonymous (not verified) |
94.188.205.168 |
Diamond Spray Foam & Coatings LLC |
Limited Liability Company |
19024 345th St, Forest City, IA 50436 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-21 |
Joshua G Diamond |
dsfinsulation@gmail.com |
Forest City |
Iowa |
United States |
Greg Diamond |
Renee Diamond |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua G Diamond |
dsfinsulation@gmail.com |
Owner |
Forest City |
Iowa |
United States |
Greg Diamond |
Renee Diamond |
Signed |
1170 |
2022-06-24 08:52 |
Anonymous (not verified) |
66.255.230.24 |
Anderson's Flying Service |
Proprietorship |
PO Box 127 Robbins, CA 95676 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-24 |
Stephen Anderson |
steve@andersonsflying.com |
YUBA CITY |
CA |
United States |
Greg Foster |
Cliff Snelling |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stephen Anderson |
steve@andersonsflying.com |
Self |
YUBA CITY |
CA |
United States |
Greg Foster |
Cliff Snelling |
Signed |
1796 |
2023-08-13 13:35 |
Anonymous (not verified) |
94.188.205.176 |
Mirsad Mulic |
Limited Liability Company |
7094 Hickory Ln |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-13 |
Mirsad Mulic |
finecarpentry30@icloud.com |
Urbandale |
Polk |
IA |
Peter Griffin |
Andy Dufre |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Fine Carpentry |
finecarpentry30@icloud.com |
Partner |
Urbandale |
Polk |
IA |
Griffin Peterson |
Andy Dufre |
Signed |
1928 |
2023-11-29 21:48 |
Anonymous (not verified) |
94.188.205.168 |
Iowa Evolution Constuction |
Partnership |
1203 Bluegrass Cir |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-01 |
Claudia Rodriguez |
claudia.rodriguez.213@gmail.com |
CEDAR FALLS |
IA |
United States |
Guillermo Nunez |
Blanca rodriguez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Claudia Rodriguez |
claudia.rodriguez.213@gmail.com |
Owner |
CEDAR FALLS |
IA |
United States |
Guillermo Nunez |
Blanca Rodriguez |
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 |
195 |
2020-06-29 08:55 |
Anonymous (not verified) |
107.77.173.23 |
E.S.T. Construction LLC |
Limited Liability Company |
2412 E 16th st Des Moines, IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-29 |
Eber Saul Torres |
estorres48@gmail.com |
Des Moines |
Polk |
Iowa |
Hailey Galdames Luna |
Abel Mejia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Eber Saul Torres |
estorres48@gmail.com |
Self |
Des Moines |
Polk |
IOWA |
Hailey Galdames Luna |
Abel Mejia |
Signed |
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 |
1413 |
2023-01-06 15:15 |
Anonymous (not verified) |
199.120.121.97 |
Jason Gaul |
Proprietorship |
1088 Ridge Lane Harlan, IA 51537 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-06 |
Jason Robert Gaul |
gauljasonr@gmail.com |
Harlan |
Shelby |
Iowa |
Haley Leinen |
Scott Leinen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jason Robert Gaul |
gauljasonr@gmail.com |
Self |
Harlan |
Shelby |
Iowa |
Haley Leinen |
Scott Leinen |
Signed |
2172 |
2024-04-22 14:09 |
Anonymous (not verified) |
94.188.205.167 |
Melissa J Madison |
Proprietorship |
326 NE Olivewood Waukee, IA 50263 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-22 |
Melissa Janelle Madison |
melissamadison01@gmail.com |
Waukee |
DALLAS |
IOWA |
Haley Sears |
Scott Leinen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melissa Madison |
melissamadison01@gmail.com |
myself |
Waukee |
Dallas |
Iowa |
Haley Sears |
Scott Leinen |
Signed |
2210 |
2024-05-07 19:15 |
Anonymous (not verified) |
94.188.207.229 |
Greenelectric |
Proprietorship |
407 Drury Lane |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-07 |
Harold Carr |
handbcarr@hotmail.com |
Legrad |
Iowa |
Iowa |
Harold Dale Carr |
Harold Dale Carr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Harold Carr |
handbcarr@hotmail.com |
I am the owner |
Legrad |
Iowa |
Iowa |
Harold Dale Carr |
Harold Dale Carr |
Signed |
1914 |
2023-11-20 16:05 |
Anonymous (not verified) |
94.188.207.227 |
Dark Horse Transport LLC |
Limited Liability Company |
301 Lincoln St, Brayton, IA 50042 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-20 |
James William Meese |
bethany.dhtllc@gmail.com |
Brayton |
Audubon |
Iowa |
Hayley Meese-Cherry |
Wyatt Jessen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Wiliam Meese |
bethany.dhtllc@gmail.com |
Owner |
Brayton |
Audubon |
Iowa |
Hayley Meese-Cherry |
Wyatt Jessen |
Signed |
442 |
2021-03-22 12:14 |
Anonymous (not verified) |
149.20.235.228 |
Tim Bruck Construction Inc. |
Proprietorship |
348 Highway 44 Rd. Porstmouth, IA 51565 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-22 |
Timothy Richard Bruck |
timrbruck@gmail.com |
Portsmouth |
Shelby |
Iowa |
Heath Ryan Stein |
Faith Nicole Bruck |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tim Richard Bruck |
timrbruck@gmail.com |
Self |
Portsmouth |
Shelby |
Iowa |
Heath Ryan Stein |
Faith Nicole Bruck |
Signed |
1523 |
2023-03-18 13:15 |
Anonymous (not verified) |
94.188.207.223 |
Aguilera’s Lawn Care LLC |
Limited Liability Company |
827 17th Street Southeast, Altoona, 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. |
2023-03-18 |
Jose Aguilera |
aguileramowing20@gmail.com |
Altoona |
IA |
United States |
Heather Aguilera |
Heather Aguilera |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Aguilera |
aguileramowing20@gmail.com |
Self- owner |
Altoona |
IA |
United States |
Heather Aguilera |
Heather Aguilera |
Signed |
1595 |
2023-04-24 12:34 |
Anonymous (not verified) |
94.188.205.166 |
Ankeny & Neighbors |
Proprietorship |
603 South St, Cambridge Iowa 50046 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-24 |
William Richard Borchard III |
william@damageddevicerepair.com |
Cambridge |
Story |
Iowa |
Heather Borchard |
Mark Densmond |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Borchard III |
william@damageddevicerepair.com |
Sole proprietor/owner |
Cambridge |
Story |
Iowa |
Heather Borchard |
Mark Densmore |
Signed |
275 |
2020-10-08 11:56 |
Anonymous (not verified) |
166.224.213.71 |
Michael corcoran |
Proprietorship |
311 e elm st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-07 |
Michael corcoran |
mikecorcoran1990@gmail.com |
West Union |
Fayette |
IA |
Heather corcoran |
Chris Fels |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael corcoran |
mikecorcoran1990@gmail.com |
Self |
West Union |
Fayette |
IA |
Heather corcoran |
Chris fels |
Signed |
48 |
2020-01-29 13:52 |
Anonymous (not verified) |
97.64.170.98 |
DARIN J. KESSLER |
Proprietorship |
1236 25TH ST AMES, IA 50010 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-29 |
DARIN J. KESSLER |
darinjkessler@gmail.com |
AMES |
STORY |
IOWA |
HEATHER DIANNE LANNING |
JENNY ANN ARENDS |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
DARIN J. KESSLER |
darinjkessler@gmail.com |
SELF |
AMES |
STORY |
IOWA |
HEATHER DIANNE LANNING |
JENNY ANN ARENDS |
Signed |
1899 |
2023-11-09 16:55 |
Anonymous (not verified) |
94.188.207.227 |
Factory Services |
Limited Liability Company |
2444 Elm 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. |
2023-11-09 |
Mark Farrell |
markfa12@yahoo.com |
Fort Dodge |
Webster |
Iowa |
Heather Farrell |
Karson Farrell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Farrell |
markfa12@yahoo.com |
Owner |
Fort Dodge |
Webster |
Iowa |
Heather Farrell |
Karson12 |
Signed |
2107 |
2024-03-19 12:33 |
Anonymous (not verified) |
94.188.205.175 |
Elit Construction and Masonry LLC |
Partnership |
3309 Wright St. Des Moines, Ia 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-19 |
Manuel Mejia |
elitconstructionmasonryllc@gmail.com |
Des Moines |
Polk |
Iowa |
Heather Garber |
Kyle Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Manuel Mejia |
elitconstructionmasonryllc@gmail.com |
self |
Des Moines |
Polk |
Iowa |
Heather Garber |
Kyle Johnson |
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 |
719 |
2021-11-05 13:48 |
Anonymous (not verified) |
174.198.66.202 |
James Johnson Ace Floor Guys |
Proprietorship |
521 29th st 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. |
2020-08-13 |
James Johnson |
acefloorguysia@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Johnson |
acefloorguysia@gmail.com |
Self Employed |
Cedar Rapids |
Linn |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
720 |
2021-11-05 13:57 |
Anonymous (not verified) |
209.252.172.87 |
Rick Klemesrud Brookstin Flooring |
Proprietorship |
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. |
(1) I am not electing the employers’ liability coverage. |
2020-05-23 |
Rick Klemesrud |
installation@bachmeiercarpetone.com |
Coralville |
Johnson |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rick Klemesrud |
installation@bachmeiercarpetone.com |
Self |
Croalville |
Johnson |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
1057 |
2022-04-18 12:53 |
Anonymous (not verified) |
204.16.59.10 |
Iowa’s Gutter Specialist LLC |
Limited Liability Company |
1390 Lark Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-18 |
Dustin Halverson |
dh42312695@gmail.com |
Hampton |
IA |
United States |
Heather Halverson |
Michael Halverson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Halverson |
dh42312695@gmail.com |
Owner |
Hampton |
IA |
United States |
Heather Marie Halverson |
Michael Alexander Halverson |
Signed |
691 |
2021-10-26 14:54 |
Anonymous (not verified) |
65.144.174.26 |
Alfonso Montoya |
Proprietorship |
2114 Nw Maple 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. |
2021-10-26 |
Alfonso Montoya |
fonzflooring@gmail.com |
Des Moines |
Polk |
Iowa |
Hector Montoya |
Victor Montoya |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alfonso Montoya |
fonzflooring@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Hector Montoya |
Victor Montoya |
Signed |
1533 |
2023-03-25 10:24 |
Anonymous (not verified) |
94.188.207.226 |
Doug Uridil |
Proprietorship |
616 16th Street NE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-22 |
Doug Uridil |
douguridil@gmail.com |
Cedar Rapids |
United States |
IOWA |
Heidi Vincent |
Molly Coffman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Doug Uridil |
douguridil@gmail.com |
Self |
Cedar Rapids |
United status |
IOWA |
Heidi Vincent |
Molly Kaufman |
Signed |
1061 |
2022-04-19 19:30 |
Anonymous (not verified) |
172.58.83.52 |
Rodolfo Perez |
Proprietorship |
3420 E 12th St Des Moines 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. |
2022-04-19 |
Rodolfo Perez |
Elgordo0738@gmail.com |
Des Moines |
Polk |
Iowa |
Henry santos |
Larry ramos |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Lantz |
Info@lantzelite.com |
Self employed no workers |
Urbandale |
Polk |
Iowa |
Henry santos |
Larry ramos |
Signed |
1122 |
2022-05-21 12:19 |
Anonymous (not verified) |
173.24.108.210 |
Daly Building Service,LLc |
Limited Liability Company |
409 Dammann dr. Eldridge IA, 52748 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-21 |
Noah Daly |
Noahdalyubs@gmail.com |
Eldridge |
Scott County |
Iowa |
Holly Roberts |
Corinna Daly |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derick Perry |
biglakellc@outlook.com |
Liability policy agent |
Eldridge |
Scott county |
Iowa |
Holly roberts |
Corinna Daly |
Signed |
11 |
2019-12-17 19:46 |
Anonymous (not verified) |
50.83.188.192 |
B & B Construction |
Proprietorship |
2463 93rd Avenue, 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. |
2019-12-17 |
Louis I. Maxwell |
brockbrooke2463@yahoo.com |
Norwalk |
IA |
United States |
Hope Winegardner |
Yvonne Ginther |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Louis Maxwell |
brockbrooke2463@yahoo.com |
Owner |
Norwalk |
IA |
United States |
Hope Winegardner |
Yvonne Ginther |
Signed |
754 |
2021-11-19 08:27 |
Anonymous (not verified) |
65.144.174.26 |
miguel albino |
Proprietorship |
8760 cody dr. unit 107 west des moines |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
miguel albino |
albino.miguel627@gmail.com |
west des moines |
united states |
iowa |
humbeto albino |
johnothan albino |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
miguel albino |
albino.miguel627@gmail.com |
self |
west des moines |
united states |
iowa |
humberto albino |
johnothan |
Signed |
1832 |
2023-09-08 12:01 |
Anonymous (not verified) |
94.188.207.226 |
GFORCE |
Limited Liability Company |
529 Anderson Street Jewell IA 50130 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-06 |
Scott Andrew Griffin |
G6@q.com |
Jewell |
Hamilton |
Iowa |
Colten Abram Griffin |
Hunter Austin Griffin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Colten Abram Griffin |
G6@q.com |
Partner |
Ames |
Story |
Iowa |
Hunter Austin Griffin |
Scott Andrew Griffin |
Signed |
1864 |
2023-10-09 09:52 |
Anonymous (not verified) |
94.188.207.223 |
Admiral Staffing Inc |
Limited Liability Company |
580 8th Ave, 15th Floor, New York NY 10018 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-09 |
Rezwan Rafeek |
ray@admiralstaffinginc.com |
23 Catalpa Lane |
Valley Stream |
NY |
Ikbal Sherif |
Salim Balee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shafi Rafeek |
shafi@admiralstaffinginc.com |
Office Manager |
New York |
NY |
United States |
Ikbal Sherif |
Salin Balee |
Signed |
1150 |
2022-06-10 16:14 |
Anonymous (not verified) |
173.29.125.38 |
Vernon Tim McClain |
Limited Liability Company |
2717 Thompson ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-10 |
Vernon Tim McClain |
mcclainlawn@gmail.com |
Des Moines |
POlk |
Iowa |
Ilisha Carter |
Earl Warren Jr. |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
vernon mcclain |
mcclainlawn@gmail.com |
business owner |
des moines |
polk |
iowa |
Ilisha Carter |
Earl Warren Jr. |
Signed |
1750 |
2023-07-17 11:00 |
Anonymous (not verified) |
94.188.205.166 |
Mario Flores |
Proprietorship |
2101 E Virginia Ave. Apt 1 Des Moines, Iowa 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-22 |
Mario Zubia Flores |
deb@piciowa.com |
Des Moiines |
Polk |
Iowa |
Inspro employee 2022 |
Inspro employee 2022 |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mario Zubia Flores |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Inspro employee 2022 |
Inspro employee 2022 |
Signed |
1751 |
2023-07-17 11:00 |
Anonymous (not verified) |
94.188.205.166 |
Mario Flores |
Proprietorship |
2101 E Virginia Ave. Apt 1 Des Moines, Iowa 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-22 |
Mario Zubia Flores |
deb@piciowa.com |
Des Moiines |
Polk |
Iowa |
Inspro employee 2022 |
Inspro employee 2022 |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mario Zubia Flores |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Inspro employee 2022 |
Inspro employee 2022 |
Signed |