Official State of Iowa Website Here is how you know
Agencies A-Z Programs & Services
  1. Nonelection of Workers' Compensation or Employers' Liability Coverage
  2. Table

Nonelection of Workers' Compensation or Employers' Liability Coverage

Primary tabs

Secondary tabs

Showing 2201 - 2227 of 2227.   Show 10 | 50 | 100 | 200 | 500 | 1000 | All results per page.
# Submitted User IP address Name of Employer: Type of Entity: Address of Employer's Home Office: Statement 1 Agreement: Statement 2 Agreement: Statement 3 Agreement: Understanding Confirmation: Check Either Alternative (1) or (2): Date: Full Name of Individual: Email: City of Residence: County of Residence: State of Residence: Full Name of Witness 1: Full Name of Witness 2: Signing Indication: Check either alternative (1) or (2): Full Name of Authorized Agent: Email of Authorized Agent: Relationship to Employer of Authorized Agent: City of Residence: County of Residence: State of Residence: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Indication:
1396 2022-12-19 18:35 Anonymous (not verified) 174.198.65.20 Flyover Productions LLC Limited Liability Company 300 S Clinton 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. 2022-12-19 Richard A Redfern richredfern3@gmail.com Iowa City IA United States Susan Redfern Aditi Reddy Signed (1) The employer does not elect the employers’ liability coverage. Richard Redfern richredfern3@gmail.com Owner of company Iowa City Iowa United States Susan Redfern Aditi Reddy Signed
571 2021-07-12 09:51 Anonymous (not verified) 67.55.237.31 Steve Vogel Proprietorship 314 NE 2ND ST. Panora, Iowa 50216-2020 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-12 Steve Vogel thevogels@netins.net PANORA Guthrie United States Diana Vogel Adam Vogel Signed (1) The employer does not elect the employers’ liability coverage. Steve Vogel thevogels@netins.net Self PANORA Guthrie Iowa Diana Vogel Adam Vogel Signed
785 2021-12-09 09:15 Anonymous (not verified) 174.198.75.71 Daniel Vega camacho Proprietorship 2415 river ,meadows drive 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. 2021-12-09 Daniel Vega camacho dvega50265@gmail.com Des Moines Polk Iowa Chad Smith Adam Smith Signed (1) The employer does not elect the employers’ liability coverage. Daniel Vega camacho dvega50265@gmail.com Self Des Moines Polk Iowa Chad Smith Adam Smith Signed
1134 2022-05-31 09:08 Anonymous (not verified) 65.125.92.130 EAC Multi-Services, Inc, Proprietorship 6224 Forest Ave. Des Moines, IA 50311 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-31 Alan E Enamordo enriqueecalowcare@gmail.com Des Moines Polk Iowa Chad Smith Adam Smith Signed (1) The employer does not elect the employers’ liability coverage. Alan E Enamordo enriqueecalowcare@gmail.com self Des Moines Polk IA Chad Smith Adam Smith Signed
1171 2022-06-24 09:40 Anonymous (not verified) 65.125.92.130 Vega's Pro Painting, LLC Limited Liability Company 2415 River Meadows Dr. 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. 2022-06-24 Daniel Vega Camacho dvega50265@gmail.com Des Moines Polk IA Chad Smith Adam Smith Signed (1) The employer does not elect the employers’ liability coverage. Daniel Vega Camacho dvega50265@gmail.com Self Des Moines Polk IA Chad Smith Adam Smith Signed
1912 2023-11-16 08:40 Anonymous (not verified) 94.188.205.175 JC LANDSCAPING & LAWN CARE Proprietorship 4940 E. SHERIDAN AVE 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. 2023-11-16 CLAUDIA TORO PINEDA CLAUDIAMEP@HOTMAIL.COM DES MOINES POLK IA BRENDA REEDY ADAM SMITH Signed (1) The employer does not elect the employers’ liability coverage. CLAUDIA TORO PINEDA CLAUDIAMEP@HOTMAIL.COM SELF DES MOINES POLK IA BRENDA REEDY ADAM SMITH Signed
590 2021-07-29 16:38 Anonymous (not verified) 138.43.237.95 Choice Ag Services INC Proprietorship 1841 Firefly Rd, Manchester, IA 52057 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-29 Joshua Arthur Soppe choiceagservices@gmail.com Manchester Delaware Iowa Dustin Fessler Adam Reth Signed (1) The employer does not elect the employers’ liability coverage. Joshua Arthur Soppe choiceagservices@gmail.com Owner Manchester Delaware Iowa Dustin Fessler Adam Reth Signed
591 2021-07-29 16:42 Anonymous (not verified) 138.43.237.95 Choice Ag Services INC Proprietorship 1841 Firefly Rd, Manchester, IA 52057 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-29 Dustin Fessler dustin@choiceagservices.com Manchester IA United States Josh Soppe Adam Reth Signed (1) The employer does not elect the employers’ liability coverage. Dustin Fessler dustin@choiceagservices.com Owner Manchester Delaware Iowa Josh Soppe Adam Reth Signed
1662 2023-05-25 12:52 Anonymous (not verified) 94.188.205.176 Affordable Painting and Renovations of Iowa LLC Limited Liability Company 1418 NW Applewood St. 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. 2023-05-25 Bryan Thieleke affordablerenoiowa@yahoo.com Ankeny Polk Iowa Mike Kaut Adam Lozano Signed (1) The employer does not elect the employers’ liability coverage. Bryan Thieleke affordablerenoiowa@yahoo.com Owner Ankeny Polk Iowa Mike kaut Adam lozano Signed
1663 2023-05-25 12:56 Anonymous (not verified) 94.188.205.167 Affordable Painting and Renovations of Iowa LLC Limited Liability Company 1417 NW Applewood St. 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. 2023-05-25 Bryan Thieleke affordablerenoiowa@yahoo.com Ankeny Polk Iowa Mike kaut Adam lozano Signed (1) The employer does not elect the employers’ liability coverage. Bryan Thieleke affordablerenoiowa@yahoo.com Owner Ankeny Polk Iowa Mike kaut Adam lozano Signed
624 2021-08-30 15:53 Anonymous (not verified) 174.253.66.113 Leaf Home Solutions LLC Limited Liability Company 1595 Georgetown 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. 2021-08-30 Chad York Cyork027@gmail.com Davenport Scott Iowa Chad York Adam Coleman Signed (1) The employer does not elect the employers’ liability coverage. Adam Coleman ARColeman@leafhome.com Recruiter Hudson Summit Ohio Chad York Adam Coleman Signed
217 2020-07-27 14:56 Anonymous (not verified) 72.2.163.232 Calvin Kroger Proprietorship 48232 292nd St. Hudson, SD 57034 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-27 Calvin Kroger calvinkroger@gmail.com Hudson Lincoln South Dakota Robin Anderson Adam Anderson Signed (1) The employer does not elect the employers’ liability coverage. Calvin Kroger calvinkroger@gmail.com proprietor Hudson Lincoln South Dakota Robin Anderson Adam Anderson Signed
258 2020-09-15 13:14 Anonymous (not verified) 50.83.182.140 Moyer Painting Proprietorship 934 Norwood Drive I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-15 jerome Moyer moyer_painting@live.com Norwalk IA United States Sally Moyer Adam Adams Signed (1) The employer does not elect the employers’ liability coverage. jerome b moyer moyer_painting@live.com Self norwalk IA United States sally moyer Adam Adams Signed
666 2021-10-07 08:12 Anonymous (not verified) 208.126.166.149 Toribio Construction LLC Limited Liability Company 107 W Maxson 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. 2020-10-07 Jose Toribio osorioabigail0224@gmail.com West Liberty Muscatine IA Anthony Johnson Abigail Osorio Signed (1) The employer does not elect the employers’ liability coverage. Jose Toribio osorioabigail0224@gmail.com Owner West Liberty Muscatine IA Anthony Johnson Abigail Osorio Signed
770 2021-11-22 18:17 Anonymous (not verified) 192.82.97.13 Paul Wire Proprietorship 1005 25th Street SW, Spencer, IA 51301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-22 Paul Wire gizzmochee@gmail.com Spencer Clay IA Lori Wire Abigail Miles Signed (1) The employer does not elect the employers’ liability coverage. Paul Wire gizzmochee@gmail.com Self Spencer Clay IA Lori Wire Abigail Miles 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
1691 2023-06-14 19:20 Anonymous (not verified) 94.188.205.174 Amazing Painting LLC Limited Liability Company 1301 Boyd Street, 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. 2023-06-14 Evan Michael Regenwether Evan@amazingpaintingia.com Des Moines Polk Iowa Austin Matthew Regenwether Abby Marie Regenwether Signed (1) The employer does not elect the employers’ liability coverage. Evan Michael Regenwether evan@amaingpaintingia.com Owner Des Moines Polk Iowa Austin Matthew Regenwether Abby Regenwether Signed
698 2021-10-28 16:09 Anonymous (not verified) 71.228.88.54 Warren Nelson Proprietorship 2525 Nebraska Street, 106, Sioux City, Iowa 51104 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-28 Scott D. Nelson scottdnelson@hotmail.com Sioux City Woodbury Iowa Wallace E Sheets Abby McDermott Signed (1) The employer does not elect the employers’ liability coverage. Beth L Sheets w143bs@verizon.net Daughter Sarasota Manatee Florida Wallace E. Sheets Abby McDermott Signed
1483 2023-02-25 14:57 Anonymous (not verified) 94.188.205.168 Van Wyk Lawn Services Limited Liability Company 14486 S. 128th ave E. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-24 Anthony Eugene Van Wyk vanwykturf@gmail.com Lynnville Iowa United States Ashley Lynn Van Wyk Abby Christine Peterson Signed (1) The employer does not elect the employers’ liability coverage. Anthony Eugene Van Wyk vanwykturf@gmail.com Self/Owner Lynnville Iowa United States Ashley Lynn Van Wyk Abby Christine Peterson Signed
324 2020-11-20 09:08 Anonymous (not verified) 71.39.227.238 County-Line Construction, LLC Limited Liability Company 314 NE 2nd St, Panora, IA 50216 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-20 John Steve Vogel thevogels@netins.net Panora Guthrie Iowa Steve Phillips Abbey Luellen Signed (1) The employer does not elect the employers’ liability coverage. John Steve Vogel thevogels@netins.net Owner Panora Guthrie Iowa Steve Phillips Abbey Luellen Signed
422 2021-03-05 13:53 Anonymous (not verified) 71.39.227.238 Steven Phillips Proprietorship 1107 Walnut St, Dallas Center, IA 50063 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-06 Steven Phillips stevep@phillipsassociatesins.net Linden Guthrie Iowa Abbey Luellen RoseMary Phillips Signed (1) The employer does not elect the employers’ liability coverage. Steven Phillips stevep@phillipsassociatesins.net Self Linden Guthrie Iowa RoseMary Phillips Abbey Luellen Signed
423 2021-03-05 13:55 Anonymous (not verified) 71.39.227.238 RoseMary Phillips Proprietorship 1107 Walnut St, Dallas Center, IA 50063 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-05 RoseMary Phillips stevep@phillipsassociatesins.net Linden Guthrie Iowa Steven Phillips Abbey Luellen Signed (1) The employer does not elect the employers’ liability coverage. RoseMary Phillips stevep@phillipsassociatesins.net Self Linden Guthrie Iowa Steve Phillips Abbey Luellen Signed
621 2021-08-27 16:11 Anonymous (not verified) 71.39.227.238 DOUG WEISS DBA DIRTWORKS Proprietorship 23966 MIDLAND TRAIL, DALLAS CENTER, IA 50063 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-27 DOUG WEISS EWEISSN03.EW@GMAIL.COM DALLAS CENTER DALLAS IOWA DON RICHARDSON ABBEY LUELLEN Signed (1) The employer does not elect the employers’ liability coverage. DOUG WEISS EWEISSN03.EW@GMAIL.COM SELF DALLAS CENTER DALLAS IOWA DON RICHARDSON ABBEY LUELLEN Signed
622 2021-08-27 16:12 Anonymous (not verified) 71.39.227.238 DOUG AND ELLEN WEISS DBA DIRTWORKS Proprietorship 23966 MIDLAND TRAIL, DALLAS CENTER, IA 50063 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-27 ELLEN WEISS EWEISSN03.EW@GMAIL.COM DALLAS CENTER DALLAS IOWA DON RICHARDSON ABBEY LUELLEN Signed (1) The employer does not elect the employers’ liability coverage. ELLEN WEISS EWISSN03.EW@GMAIL.COM SELF DALLAS CENTER DALLAS IOWA DON RICHARDSON ABBEY LUELLEN Signed
1080 2022-04-29 08:59 Anonymous (not verified) 216.51.225.18 Lee's Haul It & Property Care Proprietorship 212 Village Dr #5, Tiffin, IA 52340 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-29 Tim Lee timclee160@gmail.com Tiffin Johnson Iowa Lee Krueger Aaron Oehring Signed (1) The employer does not elect the employers’ liability coverage. Lee's Haul It & Property Care leeshaulit@gmail.com Owner Tiffin Johnson Iowa Tim Lee Aaron Oehring Signed
1243 2022-08-04 21:00 Anonymous (not verified) 173.24.221.228 Foreman's Tile Creations Proprietorship 1412 Franklin 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. 2022-08-04 Sole Proprietor fudog4man@gmail.com Center Point Linn IA Aaron Foreman Aaron Foreman Signed (1) The employer does not elect the employers’ liability coverage. Aaron Foreman fudog4man@gmail.com I am the Employer Center Point Linn IA Aaron Foreman Aaron Foreman Signed
1366 2022-11-10 09:33 Anonymous (not verified) 172.58.87.232 Blackstone Handy Services, LLC Limited Liability Company 1807 B Avenue Northeast I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-10 jovan walton blackstonehandyservices@gmail.com Cedar Rapids IA United States Mekaylah K. Stevens Dominique T. Walton Signed (1) The employer does not elect the employers’ liability coverage. jovan walton blackstonehandyservices@gmail.com Self Cedar Rapids Linn United States Mekaylah K. Stevens Dominique T. Walron Signed