54 |
2020-02-06 14:18 |
Anonymous (not verified) |
173.28.28.57 |
Dale Hansman dba Klinkenborg Hansmann Law Office |
Proprietorship |
1201 Hwy 57, Parkersburg, IA 50665 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-14 |
Dale Hansmann |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dale Hansmann |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
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 |
1744 |
2023-07-13 13:52 |
Anonymous (not verified) |
94.188.205.176 |
T-Rex Construction LLC |
Limited Liability Company |
1203 Bluegrass Circle Unit 4 Cedar Falls Iowa 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-12 |
Claudia Rodriguez De Nunez |
t.rexbigbiz@gmail.com |
CEDAR FALLS |
IA |
United States |
Ana Chavez |
Alicia Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Guillermo Nunez |
claudia.rodriguez.213@gmail.com |
Spouse |
CEDAR FALLS |
IA |
United States |
Alicia Garcia |
Ana Chavez |
Signed |
558 |
2021-07-07 13:35 |
Anonymous (not verified) |
66.188.136.150 |
Austin Kalfus Sr. |
Proprietorship |
1203 Poppy Ave. Pensacola, FL 32507 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-07 |
Austin Kalfus Sr. |
kschumacher@tricorinsurance.com |
Pensacola |
Escambia |
FL |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Austin Kalfus Sr. |
kschumacher@tricorinsurance.com |
Same |
Pensacola |
Escambia |
FL |
Mitch Kemp |
Shuree Behr |
Signed |
388 |
2021-02-10 11:48 |
Anonymous (not verified) |
97.125.123.32 |
Pro Bull Painting LLC |
Limited Liability Company |
1204 sampson 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. |
2021-02-10 |
Eduardo Garcia Becerril |
probullpainting1@gmail.com |
Des Moines |
Polk |
Iowa |
Juan Carlos Garcia |
Rigoberto Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Eduardo Garcia |
Probullpainting1@gmail.com |
Owner |
Des moines |
Polk |
Iowa |
Juan Carlos Garcia |
Rigoberto Garcia |
Signed |
792 |
2021-12-14 13:18 |
Anonymous (not verified) |
173.31.148.43 |
BLUE WAVE SETTLEMENT LLC |
Limited Liability Company |
1205 H AVENUE 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. |
2021-12-14 |
SHANNON NORTON |
NOERTONSHANNON@YAHOO.COM |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
BLUE WAVE SETTLEMENT LLC |
NORTONSHANNON@YAHOO.COM |
SELF |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
512 |
2021-05-11 13:12 |
Anonymous (not verified) |
173.31.147.225 |
RUTHVEN ROCKS LLC |
Limited Liability Company |
1205 ROLLING ST RUTHVEN IOWA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-11 |
JEFF CACEK |
JEFF@RUTHVENROCKS.COM |
RUTHVEN |
PALO ALTO |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JEFF CACEK |
joel@walkerinsuranceia.com |
MEMBER |
RUTHVEN |
PALO ALTO |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
513 |
2021-05-11 13:14 |
Anonymous (not verified) |
173.31.147.225 |
RUTHVEN ROCKS LLC |
Limited Liability Company |
1205 ROLLING ST RUTHVEN IOWA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-11 |
KEITH CACEK |
KEITH@RUTHVENROCKS.COM |
RUTHVEN |
PALO ALTO |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KEITH CACEK |
joel@walkerinsuranceia.com |
MEMBER |
RUTHVEN |
PALO ALTO |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
514 |
2021-05-11 13:16 |
Anonymous (not verified) |
173.31.147.225 |
RUTHVEN ROCKS LLC |
Limited Liability Company |
1205 ROLLING ST RUTHVEN IOWA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-11 |
MATT CACEK |
MATT@RUTHVENROCKS.COM |
MILFORD |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MATT CACEK |
joel@walkerinsuranceia.com |
MEMBER |
MILFORD |
PALO ALTO |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
333 |
2020-12-05 08:57 |
Anonymous (not verified) |
173.25.143.97 |
Groen Pediatric Consulting |
Limited Liability Company |
1206 NE 31ST ST 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. |
2021-01-01 |
Amy Groen |
dramygroen@yahoo.com |
Ankeny |
Iowa |
United States |
Daniel Martin |
Anita Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Amy Groen |
dramygroen@yahoo.com |
self |
Ankeny |
Iowa |
United States |
Kay Martin |
Priscilla Putzier |
Signed |
1702 |
2023-06-22 22:57 |
Anonymous (not verified) |
94.188.207.230 |
A&M Consulting LLC |
Limited Liability Company |
1208 5th Ave, North Humboldt Iowa, 50548 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-22 |
maureen Waweru |
maureenrealtyaz@yahoo.com |
chandler |
AZ |
United States |
John Waweru |
Jessica Bellinger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
maureen Waweru |
maureenrealtyaz@yahoo.com |
Self |
chandler |
AZ |
United States |
John Waweru |
Jessica Bellinger |
Signed |
178 |
2020-06-08 13:51 |
Anonymous (not verified) |
173.21.16.200 |
Daniel Mullanack |
Limited Liability Company |
1208 Franklin St. Buffalo, IA 52728 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2020-06-08 |
daniel mullanack |
mullanackbuilders@mediacombb.net |
buffalo |
scott |
iowa |
brandon brooks |
amy carlson |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
linda mullanack |
mullanackbuilders@mediacombb.net |
office manager |
buffalo |
scott |
iowa |
brandon brooks |
amy carlson |
Signed |
1782 |
2023-08-04 08:04 |
Anonymous (not verified) |
94.188.207.229 |
Matt Larson Construction |
Limited Liability Company |
1208 Hazel St. Pella, IA 50219 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-04 |
Matthew Mark Larson |
larson-m@hotmail.com |
Pella |
Marion |
IA |
Brian Huddle |
Jon E. Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jon E. Miller |
stmarypella@iowatelecom.net |
Parish Secretary |
Pella |
IOWA |
United States |
Brian Huddle |
Jon E. Miller |
Signed |
752 |
2021-11-17 08:22 |
Anonymous (not verified) |
166.181.82.81 |
Michael sprout |
Limited Liability Company |
1208 N THORNWOOD 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. |
2021-10-14 |
Michael Sprout |
1293newhome@gmail.com |
Davenport |
IA |
IA |
Mike smith |
Doug palmer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Sprout |
1293newhome@gmail.com |
Geico |
Davenport |
IA |
IA |
Mike smith |
Doug palmer |
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 |
724 |
2021-11-05 14:25 |
Anonymous (not verified) |
209.252.172.87 |
Josh Peterson |
Proprietorship |
121 Karen Drive, Williamsburg, IA 52361 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-15 |
Josh Peterson |
tanyataz@msn.com |
Williamsburg |
Iowa |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Peterson |
tanyataz@msn.com |
Self Employed |
Williamsburg |
Iowa |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
1115 |
2022-05-17 19:36 |
Anonymous (not verified) |
173.23.50.204 |
Delgado Electrical Services |
Limited Liability Company |
1210 Creston Ave Des Moines, Iowa 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-17 |
Cesar Delgado |
delgado.electrical@gmail.com |
Des Moines |
Polk |
Iowa |
Mike Willet |
Alex Segovia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cesar Delgado |
cesar.delgado31@yahoo.com |
Owner |
Des Moines |
Polk |
Iowa |
Mike Willet |
Alex Segovia |
Signed |
511 |
2021-05-10 17:53 |
Anonymous (not verified) |
173.24.231.27 |
QSC Snow Removal |
Proprietorship |
1211 Carroll Boone 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. |
2021-05-10 |
Vincent A Kaylor |
phenox32@gmail.com |
Boone |
IA |
United States |
Lori Harvey |
Doug Robertson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Vincent A Kaylor |
phenox32@gmail.com |
self |
Boone |
IA |
United States |
Lori Harvey |
Doug Robertson |
Signed |
723 |
2021-11-05 14:13 |
Anonymous (not verified) |
209.252.172.87 |
Will Lacina Northstar Hardwood Floors |
Proprietorship |
1211 G St Amana, IA 52203 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Will Lacina |
northstarhardwoodfloor@gmail.com |
Amana |
Iowa |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Lacina |
northstarhardwoodfloor@gmail.com |
Self Employed |
Amana |
Iowa |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
1793 |
2023-08-09 15:23 |
Anonymous (not verified) |
94.188.205.174 |
Cesar estuardo marroquin gonzalez |
Proprietorship |
1212 David st waterloo 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. |
2023-08-09 |
Cesar estuardo marroquin gonzalez |
marroquincesar1788@gmail.com |
1212 David st waterloo iowa |
Black haw |
Iowa |
Sonia Gomez |
Sonia Gomez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cesar estuardo marroquin gonzalez |
marroquincesar1788@gmail.com |
Patrón |
1212 David st waterloo iowa |
Black hawn |
Iowa |
Sonia Gomez |
Sonia Gomez |
Signed |
1537 |
2023-03-27 13:21 |
Anonymous (not verified) |
94.188.207.228 |
miller hybrids |
Limited Liability Company |
1213 Larch Ave, Kalona, IA 52247 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Jeremy Wakerhauser |
jwakerhauser@gmail.com |
Sun Prairie |
WI |
United States |
Jeremy Wakerhauser |
Jeremy Wakerhauser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeremy Wakerhauser |
jwakerhauser@gmail.com |
sole proprieter |
Sun Prairie |
WI |
United States |
Jeremy Wakerhauser |
Jeremy Wakerhauser |
Signed |
1381 |
2022-11-30 20:41 |
Anonymous (not verified) |
97.125.145.12 |
Central Iowa Outdoor Services |
Proprietorship |
1213 Parkhill Dr. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-30 |
Keegan Eggers |
CentralIowaServices1@gmail.com |
Norwalk |
Iowa |
United States |
Stephanie Eggers |
Kelsie Eggers |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Keegan Eggers |
CentralIowaServices1@gmail.com |
Owner |
Norwalk |
Iowa |
United States |
Stephanie Eggers |
Kelsie Eggers |
Signed |
615 |
2021-08-20 16:22 |
Anonymous (not verified) |
50.81.152.147 |
CPIA Home Specialists LLC |
Limited Liability Company |
1214 13th st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-20 |
Melvin Benitez |
Benitezmelvin0@gmail.com |
Des Moines |
Iowa |
United States |
Salvador Benitez |
Zoila Benitez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melvin Benitez |
Benitezmelvin0@gmail.com |
Owner |
Des Moines |
Iowa |
United States |
Salvador Benitez |
Zoila Benitez |
Signed |
2086 |
2024-03-08 19:11 |
Anonymous (not verified) |
94.188.207.223 |
Handyman & More |
Limited Liability Company |
1214 Lindwood 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. |
2024-03-08 |
Dustin allen Bergman |
dustinbergman86@gmail.com |
Carter Lake |
IA |
United States |
Reesa Edie |
Douglas Scadin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin allen Bergman |
dustinbergman86@gmail.com |
Owner of company |
Carter Lake |
IA |
United States |
Reesa Edie |
Douglas Scadin |
Signed |
1286 |
2022-08-26 09:09 |
Anonymous (not verified) |
97.125.43.203 |
Daniel Lugo |
Proprietorship |
1217 Harold 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. |
2022-08-24 |
Daniel Lugo |
deb@piciowa.com |
Des Mpines |
Polk |
IA |
Debra Stratton |
Martin Pinon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel LUgo |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Debra Stratton |
Martin Pinon |
Signed |
2163 |
2024-04-19 08:53 |
Anonymous (not verified) |
94.188.205.174 |
George Petree |
Proprietorship |
1219 N 7th St. Burlington, IA 52601 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-19 |
George Harlan Petree |
g_petree@hotmail.com |
Burlington |
Des Moines |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
George Harlan Petree |
g_petree@hotmail.com |
owner |
Burlington |
Des Moines |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
1602 |
2023-04-25 20:10 |
Anonymous (not verified) |
94.188.207.228 |
Miguel D. |
Limited Liability Company |
1221 22nd st des moines 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. |
2021-11-21 |
Miguel Duron |
Duron6478@gmail.com |
Des moines |
Polk |
Ia |
Uziel martinez |
Cesar jaz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Miguel Duron |
Diron6478@gmail.com |
Self |
Des moines |
Polk |
Iowa |
Uziel Martinez |
Cesar jaz |
Signed |
1325 |
2022-10-02 20:07 |
Anonymous (not verified) |
50.80.107.101 |
Hanson Custom Cleanup and Removal LLC |
Limited Liability Company |
1221 Fleur Dr. 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. |
2022-10-02 |
Jason Jacob Hanson |
jasonhanson1985@gmail.com |
Waterloo |
Blackhawk |
Iowa |
Cindy Shreve |
Jacob Ring |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jason Hanson |
jasonhanson1985@gmail.com |
Self |
Waterloo |
Blackhawk |
Iowa |
Cindy Shreve |
Jacob Ring |
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 |
359 |
2021-01-12 11:37 |
Anonymous (not verified) |
173.29.116.114 |
Quad City Restorations |
Limited Liability Company |
1225 E River Drive, Suite 320, Davenport, IA 52803 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-12 |
Christopher Rogers |
chris@quadcityrestorations.com |
DAVENPORT |
Scott |
IA |
Lea Luquire |
Lisa Rubio |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christopher Rogers |
chris@quadcityrestorations.com |
Owner / Employer |
DAVENPORT |
Scott |
IA |
Lea Luquire |
Lisa Rubio |
Signed |
771 |
2021-11-22 20:29 |
Anonymous (not verified) |
75.162.65.250 |
Art Flooring LLC |
Limited Liability Company |
1225 Emma 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. |
2021-11-23 |
Antonio Rojas |
artfloorsllc@gmail.com |
1225 Emma Ave |
Polk |
Iowa |
Antonio Rojas |
Hilda Rojas |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Antonio Rojas |
artfloorsllc@gmail.com |
self |
same as above |
same as above |
iowa |
Antonio Rojas |
Hilda Rojas |
Signed |
2110 |
2024-03-21 13:29 |
Anonymous (not verified) |
94.188.205.174 |
Baroga Stone Masonry LLC |
Proprietorship |
1228 Loomis Ave 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. |
2024-03-21 |
Bacilio Rodriguez |
barogastonemasonry@gmail.com |
Des Moines |
Polk |
Iowa |
Drakkar Rapaich |
Fabi Palomares |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bacilio Rodriguez |
barogastonemasonry@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Drakkar Rapaich |
Fabi Palomares |
Signed |
102 |
2020-03-25 11:23 |
Anonymous (not verified) |
206.72.14.249 |
Brandi Wehr |
Proprietorship |
123 E Marion St, Sigourney, IA 52591 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-25 |
Brandi Jo Wehr |
brndwehr54@hotmail.com |
Sigourney |
Keokuk |
Iowa |
Amber Kephart |
Mary Beth Knipfer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chelsea Voss |
chelsea@grimmrealestate.com |
Agent |
North English |
Iowa |
Iowa |
Amber Kephart |
Mary Beth Knipfer |
Signed |
89 |
2020-03-13 12:41 |
Anonymous (not verified) |
216.96.113.16 |
B’s Sweet Treats |
Proprietorship |
123 E Marion St. Sigourney IA 52591 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-13 |
Brandi Wehr |
brndwehr54@hotmail.com |
Sigourney |
Keokuk |
IA |
Brandi |
Brandi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brandi Wehr |
brndwehr54@hotmail.com |
Same |
Sigourney |
Keokuk |
IA |
Brandi |
Brandi |
Signed |
445 |
2021-03-23 12:34 |
Anonymous (not verified) |
172.58.84.232 |
XD PAINTING |
Limited Liability Company |
1233 Herold 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. |
2021-03-23 |
Daniel Alcaraz Suarez |
xdpainting@gmail.com |
Des Moines |
Polk county |
Iowa |
Anthony Maland |
Marcus Ross |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Alcaraz Suarez |
xdpainting@gmail.com |
None |
Des Moines |
Polk county |
Iowa |
Anthony maland |
Marcus Ross |
Signed |
1901 |
2023-11-10 07:08 |
Anonymous (not verified) |
94.188.205.174 |
Elegance Exteriors |
Limited Liability Company |
1236 11th Ave N |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2023-11-10 |
Tre Trotter |
Tre@eleganceexteriors.com |
Fort Dodge |
Webster |
Iowa |
Kyle Grell |
Raenell Richardson |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Hiscox Inc. |
contact@hiscox.com |
None |
Atlanta |
Fulton |
Georgia |
Raenell Richardson |
Kyle Grell |
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 |
1605 |
2023-04-26 09:48 |
Anonymous (not verified) |
94.188.207.229 |
Double Barrell Construction |
Proprietorship |
1237 S 52nd St, #804, West Des Moines, IA 50265 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-26 |
Braedyn Baylor |
bbaylor66@gmail.com |
West Des Moines |
Polk |
IA |
Peggy Toft |
Rick Thompson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Braedyn Baylor |
bbaylor66@gmail.com |
Owner |
West Des Moines |
Polk |
IA |
Peggy Toft |
Rick Thompson |
Signed |
1897 |
2023-11-06 09:12 |
Anonymous (not verified) |
94.188.205.177 |
Matthew Jones |
Limited Liability Company |
124 NE 49th 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. |
2023-11-06 |
Matthew Jones |
mjj4242@gmail.com |
Ankeny |
Polk |
IA |
Duan Willform |
AJ Giebelstein |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Jones |
mjj4242@gmail.com |
Self |
Ankeny |
Polk |
IA |
AJ Giebelstein |
Duan Willform |
Signed |
825 |
2022-01-06 21:02 |
Anonymous (not verified) |
174.213.145.18 |
Two Brothers Tile llc |
Proprietorship |
1244 72nd St Windsor heights ia 50324 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-06 |
Senahid Mujkanovic |
xbosanacbax17@gmail.com |
Windsor Heights |
IA |
United States |
Ramiza kadric |
Senad mujkanovic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Senahid Mujkanovic |
xbosanacbax17@gmail.com |
Owner |
Windsor Heights |
IA |
United States |
Ramiza kadric |
Senad mujkanovic |
Signed |
1168 |
2022-06-23 12:57 |
Anonymous (not verified) |
74.84.106.106 |
dora valadez |
Proprietorship |
1244 e 32 nd 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. |
2022-06-23 |
dora valadez |
towens@smartind.com |
Des Moines |
Polk |
Iowa |
Tina Owens |
Kim Owens |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
dora valadez |
towens@smartind.com |
self |
Des Moines |
Polk |
Iowa |
Tina Owens |
Kim Owens |
Signed |
2162 |
2024-04-18 19:25 |
Anonymous (not verified) |
94.188.205.177 |
Escobar Enterprises, LLC |
Limited Liability Company |
125 East Broad Street, Des Moines, Iowa 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-18 |
Jesse Escobar |
jesse@escobar-enterprises.com |
Des Moines |
Polk |
Iowa |
Rene Mauricio Martinez |
Jessa Caitlin Marfal |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jesse Escobar |
jesse@escobar-enterprises.com |
owner |
Des Moines |
Polk |
Iowa |
Rene Mauricio Martinez |
Jessa Caitlin Marfal |
Signed |
1152 |
2022-06-13 13:05 |
Anonymous (not verified) |
70.96.153.153 |
Tyler Ankney |
Proprietorship |
1250 A Ave, Marion, IA 52302 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-13 |
Tyler Ankney |
tyler.a@optionsexteriors.com |
Marion |
Linn County |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tyler Ankney |
tyler.a@optionsexteriors.com |
Owner |
Marion |
Linn County |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
1513 |
2023-03-13 06:54 |
Anonymous (not verified) |
94.188.205.169 |
Tyler Ankney |
Proprietorship |
1250 A Avenue, Marion, IA 52302, United States |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-13 |
Tyler Ankney |
T_james55@ahoo.com |
Marion |
Linn County |
Iowa |
Jordan Nisiewicz |
Steve Gisler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Clay |
Missouri |
Jordan Loyd |
Steve Gisler |
Signed |
1987 |
2024-01-16 12:35 |
Anonymous (not verified) |
94.188.207.229 |
Wasabi urbandale LLc |
Limited Liability Company |
12509 Townsend Ava, Urbandale, IA 50323 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-16 |
Wen Zheng |
jenna18841002@hotmail.com |
Urbandale |
Dallas |
Iowa |
Jie Li |
Yingna Zheng |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wen Zheng |
jenna18841002@hotmail.com |
Owner |
Urbandale |
Dallas |
Iowas |
Jie Li |
Yingna zheng |
Signed |
586 |
2021-07-26 08:37 |
Anonymous (not verified) |
71.7.62.131 |
Jeffrey Knoot |
Proprietorship |
1251 Illinois Dr. Knoxville IA, 50138-8862 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-26 |
Jeffrey Jon Knoot |
opsisdental@gmail.com |
Knoxville |
Marion |
Iowa |
Sharon Kay Spriggs |
Lisa Michelle Dudley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeffrey Jon Knoot |
opsisdental@gmail.com |
self |
Knoxville |
Marion |
Iowa |
Sharon Kay Spriggs |
Lisa Michelle Dudley |
Signed |
1312 |
2022-09-17 15:29 |
Anonymous (not verified) |
97.125.242.121 |
Heartland Blinds |
Limited Liability Company |
1255 Emmons St, Hiawatha, IA 52233 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-17 |
Phil Murray |
proinstallia@yahoo.com |
Hiawatha |
Linn |
IA |
Jared Metcalf-Murray |
Jeremy Murray |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christene Murray |
chrissymurray57@yahoo.com |
Self |
Hiawatha |
Linn |
IA |
Jared Metcalf-Murray |
Jeremy Murray |
Signed |
1348 |
2022-10-28 10:19 |
Anonymous (not verified) |
208.38.230.122 |
HALSEY'S HOME IMPROVEMENTS, LLC |
Limited Liability Company |
126 SYCAMORE LANE, RIVERDALE, IOWA 52722 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-28 |
MONTY RAY HALSEY |
crickstic@gmail.com |
RIVERDALE |
SCOTT |
IA |
DARRELL MACHALEK JR. |
MATTHEW DAVISON |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MONTY HALSEY |
crickstic@gmail.com |
SELF |
RIVERDALE |
SCOTT |
IA |
DARRELL MACHALEK JR. |
MATTHEW DAVISON |
Signed |
2191 |
2024-04-29 10:09 |
Anonymous (not verified) |
94.188.207.225 |
Anthony Rakestraw |
Proprietorship |
1262 S Kellogg St., Galesburg, IL 61401 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-29 |
Anthony Rakestraw |
gazzork2@yahoo.com |
Galesburg |
Know |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Anthony Rakestraw |
gazzork2@yahoo.com |
owner |
Galesburg |
Knox |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
1722 |
2023-07-06 10:57 |
Anonymous (not verified) |
94.188.205.169 |
Brother’s Handyman Services LLC |
Proprietorship |
1270 A Avenue, Marion, IA 52302, United States |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Tyler Dahl |
handybros39@gmail.com |
Marion, IA |
Linn County |
Iowa |
Jordan Nisiewicz |
Charles Woods |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City, MO |
Johnson |
Missouri |
Charles Woods |
Jordan Loyd |
Signed |
2131 |
2024-04-02 10:28 |
Anonymous (not verified) |
94.188.205.168 |
Driskell Spray, LLC |
Limited Liability Company |
1279 300th Ave Sidney, IA 51652 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-22 |
Jamie Driskell |
driskell216@gmail.com |
Sidney |
Fremont |
Iowa |
Melinda Goy |
Rhett Goy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jamie Driskell |
driskell216@gmail.com |
owner |
Sidney |
Fremont |
Iowa |
Melinda Goy |
Rhett Goy |
Signed |
1018 |
2022-03-29 15:00 |
Anonymous (not verified) |
97.125.143.50 |
Modified Originals of Winterset |
Limited Liability Company |
128 S 3rd Ave, Winterset, IA 50273 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-29 |
Daniel Maiers |
Modifiedoriginals.winterset@gmail.com |
Winterset |
Iowa |
Iowa |
Mark Haddinger |
Josh Williams |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dan Maiers |
Modifiedoriginals.winterset@gmail.com |
Self |
Winterset |
Iowa |
Iowa |
Mark Haddinger |
Josh Williamson |
Signed |
345 |
2020-12-29 09:20 |
Anonymous (not verified) |
173.18.16.129 |
Eben-Ezer Concrete Services |
Proprietorship |
1283 dixon 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. |
2020-12-29 |
Saul Artero |
Artro50313@yahoo.com |
Des Moines |
Polk |
Iowa |
Jen Lambert |
Lesa Reeves |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Saul Artero |
Artro50313@yahoo.com |
owner |
des moines |
Polk |
Iowa |
Jen Lambert |
Lesa Reeves |
Signed |
2174 |
2024-04-24 08:22 |
Anonymous (not verified) |
94.188.205.175 |
White's Floorcovering |
Proprietorship |
129 Hillcrest Dr. Biggsville, IL 61418 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-22 |
Ron White |
hntwhite@frontiernet.net |
Biggsville |
Henderson |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ron White |
hntwhite@frontiernet.net |
owner |
Biggsville |
Henderson |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
2154 |
2024-04-16 08:05 |
Anonymous (not verified) |
94.188.207.226 |
Lanz Pork Inc |
Proprietorship |
12905 N 1050th Road, Macomb, IL 61455 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-02 |
Andrew M Riggins |
kellylanz1967@gmail.com |
Macomb |
IL |
United States |
Barb Coker |
Scott Caspall |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andrew M Riggins |
kellylanz1967@gmail.com |
Self |
Macomb |
IL |
United States |
Barb Coker |
Scott Caspall |
Signed |
2155 |
2024-04-16 08:13 |
Anonymous (not verified) |
94.188.207.225 |
Andrew M Riggins |
Proprietorship |
12905 N 1050th Road, Macomb, IL 61455 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-02 |
Andrew M Riggins |
kellylanz1967@gmail.com |
Macomb |
IL |
United States |
Barb Coker |
Scott Caspall |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andrew M Riggins |
kellylanz1967@gmail.com |
Self |
Macomb |
IL |
United States |
Barb Coker |
Scott Caspall |
Signed |
526 |
2021-05-19 09:36 |
Anonymous (not verified) |
66.188.136.150 |
John Robinson |
Proprietorship |
12990 E 48th Ave. Denver, CO 80239 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-18 |
John Robinson |
kschumacher@tricorinsurance.com |
Denver |
Denver |
CO |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Robinson |
kschumacher@tricorinsurance.com |
Same |
Denver |
Denver |
CO |
Mitch Kemp |
Shuree Behr |
Signed |
67 |
2020-02-19 10:16 |
Anonymous (not verified) |
198.167.182.164 |
AWF579 LLC |
Limited Liability Company |
13 Lynden Dr NE, Iowa City, IA 52240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-18 |
Jeffrey Schiltz |
jeffschiltz2@yahoo.com |
Iowa City |
Johnson |
Iowa |
Kyle Stahle |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeffrey Schiltz |
jeffschiltz2@yahoo.com |
Managing Member |
Iowa City |
Johnson |
Iowa |
Kyle Stahle |
Dyan Kriener |
Signed |
530 |
2021-05-25 08:30 |
Anonymous (not verified) |
159.242.43.24 |
FoxTrot Foods, LLC |
Limited Liability Company |
13-15 S Federal Ave, Mason City IA 50401 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-25 |
Melissa Fabian |
melissafabian@yahoo.com |
Mason City |
Cerro Gordo |
Iowa |
Jenny McIntyre |
Dan Wunschel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melissa Fabian |
melissafabian@yahoo.com |
Owner-Member |
Mason City |
Cerro Gordo |
Iowa |
Jenny McIntyre |
Dan Wunschel |
Signed |
909 |
2022-02-10 08:03 |
Anonymous (not verified) |
166.181.83.242 |
Kim Hildebrand |
Proprietorship |
130 Sabrina cir Waterloo, IA 50703 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-07 |
Kimberly Kay Hildebrand |
kimregenold@yahoo.com |
Waterloo |
Blackhawk |
Iowa |
Darrin Hildebrand |
Stephanie Nerison |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kimberly Kay Hildebrand |
kimregenold@yahoo.com |
Self |
Waterloo |
Blackhawk |
Iowa |
Darrin Hildebrand |
Stephanie Nerison |
Signed |
339 |
2020-12-15 15:23 |
Anonymous (not verified) |
74.221.46.229 |
CORRECTIONVILLE GOLF CLUB INC |
Limited Liability Company |
1300 HACKBERRY STREET CORRECTIONVILLE IA 51016 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-15 |
KATIE EDWARDS |
KEDWARDS@FNBCORRECTIONVILLE.COM |
CORRECTIONVILLE |
WOODBURY |
IA |
CANDACE JACOBSON |
AMBER HANSEN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KIM MEBIUS |
KMEBIUS@FNBCORRECTIONVILLE.COM |
PRESIDENT |
CORRECTIONVILLE |
WOODBURY |
IA |
CANDACE JACOBSON |
AMBER HANSEN |
Signed |
1059 |
2022-04-19 15:06 |
Anonymous (not verified) |
64.186.23.83 |
CORRECTIONVILL GOLF CLUB, INC |
Limited Liability Company |
1300 HACKBERRY STREET, CORRECTIONVILLE IOWA 51016 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
NICK HEATH |
dogboy3485@yahoo.com |
CORRECTIONVILLE |
WOODBURY |
IOWA |
CANDACE JACOBSON |
AMBER HANSEN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KATIE EDWARDS |
kedwards@fnbcorrectionville.com |
SEC/TREASURER |
CORRECTIONVILLE |
WOODBURY |
IOWA |
CANDACE JACOBSON |
AMBER HANSEN |
Signed |
1060 |
2022-04-19 15:08 |
Anonymous (not verified) |
64.186.23.83 |
CORRECTIONVILLE GOLF CLUB, INC |
Limited Liability Company |
1300 HACKBERRY STREET, CORRECTIONVILLE IOWA 51016 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
ADAM KELLY |
dslkraz@gmail.com |
CORRECTIONVILLE |
WOOD |
IWOA |
CANDACE |
AMBER HANSEN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KATIE EDWARDS |
kedwards@fnbcorrectionville.com |
SEC/TREASURER |
CORRECTIONVILLE |
WOODBURY |
IOWA |
CANDACE JACOBSON |
AMBER HANSEN |
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 |
648 |
2021-09-21 10:03 |
Anonymous (not verified) |
97.125.32.164 |
Manuel Morales |
Proprietorship |
1302 13th St Des Moines, Iowa 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. |
2021-09-15 |
Manuel Morales |
deb@piciowa.com |
Des Moines |
Polk |
Iowa |
Deb Stratton |
Kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Manuel Morales |
deb@picowa.com |
subcontractor |
Des Moines |
Polk |
Iowa |
Deb Stratton |
Kelly Denger |
Signed |
106 |
2020-03-31 10:42 |
Anonymous (not verified) |
209.152.77.101 |
Bart Fuller & James Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln ST., Ruthven, IA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-31 |
Bart Fuller |
goffins@ruthventel.com |
Ruthven |
Palo Alto |
Iowa |
Janice Henningsen |
Louise Helmke |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bart Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
Palo Alto |
Iowa |
Janice Henningsen |
Louise Helmke |
Signed |
107 |
2020-03-31 10:47 |
Anonymous (not verified) |
209.152.77.101 |
Bart Fuller & James Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln ST., Ruthven, IA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-31 |
James Fuller |
goffins@ruthventel.com |
Ruthven |
Palo Alto |
Iowa |
Janice Henningsen |
Louise Helmke |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
Palo Alto |
Iowa |
Janice Henningsen |
Louise Helmke |
Signed |
461 |
2021-04-06 08:49 |
Anonymous (not verified) |
209.152.77.101 |
Bart Fuller & James Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln ST., Ruthven, IA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-06 |
Bart Fuller |
goffins@ruthventel.com |
Ruthven |
Palo Alto |
Iowa |
Louise Helmke |
Janice Henningsen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bart Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
Palo Alto |
Iowa |
Louise Helmke |
Janice Henningsen |
Signed |
975 |
2022-03-15 10:34 |
Anonymous (not verified) |
209.152.77.101 |
Bart Fuller & James Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln ST., Ruthven, IA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-15 |
Bart Fuller |
goffins@ruthventel.com |
Ruthven |
Palo Alto |
Iowa |
Louise Helmke |
Janice Henningsen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bart Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
Palo Alto |
Iowa |
Louise Helmke |
Janice Henningsen |
Signed |
976 |
2022-03-15 10:44 |
Anonymous (not verified) |
209.152.77.101 |
Bart Fuller & James Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln ST., Ruthven, IA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-15 |
James Fuller |
goffins@ruthventel.com |
Ruthven |
Palo Alto |
Iowa |
Louise Helmke |
Janice Henningsen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
Palo Alto |
Iowa |
Louise Helmke |
Janice Henningsen |
Signed |
1516 |
2023-03-14 09:00 |
Anonymous (not verified) |
94.188.207.225 |
Bart Fuller & James Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln ST., Ruthven, IA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-14 |
Bart Fuller |
goffins@ruthventel.com |
Ruthven |
Palo Alto |
Iowa |
Louise Helmke |
Janice Henningsen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bart Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
Palo Alto |
Iowa |
Louise Helmke |
Janice Henningsen |
Signed |
1517 |
2023-03-14 09:06 |
Anonymous (not verified) |
94.188.207.230 |
Bart Fuller & James Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln ST., Ruthven, IA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-14 |
James Fuller |
goffins@ruthventel.com |
Ruthven |
Palo Alto |
Iowa |
Louise Helmke |
Janice Henningsen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
Palo Alto |
Iowa |
Louise Helmke |
Janice Henningsen |
Signed |
462 |
2021-04-06 08:56 |
Anonymous (not verified) |
209.152.77.101 |
Bart Fuller & James Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln ST., Ruthven,IA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-06 |
James Fuller |
goffins@ruthventel.com |
Ruthven |
Palo Alto |
Iowa |
Louise Helmke |
Janice Henningsen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
Palo Alto |
Iowa |
Louise Helmke |
Janice Henningsen |
Signed |
2140 |
2024-04-09 09:28 |
Anonymous (not verified) |
94.188.205.175 |
Bart Fuller& James Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln Street Ruthven, IA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-09 |
Bart Fuller |
goffins@ruthventel.com |
Ruthven |
Palo Alto |
Iowa |
Kathryn Kelley |
Janice Henningsen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bart Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
PAlo Alto |
Iowa |
Kathryn Kelley |
Janice Henningsen |
Signed |
2141 |
2024-04-09 09:34 |
Anonymous (not verified) |
94.188.205.177 |
Bart Fuller & James Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln Street Ruthven, IA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-09 |
James Fuller |
goffins@ruthventel.com |
Ruthven |
Palo Alto |
Iowa |
Kathryn Kelley |
Janice Henningsen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
Palo Alto |
Iowa |
Kathryn Kelley |
Janice Henningsen |
Signed |
2142 |
2024-04-09 09:39 |
Anonymous (not verified) |
94.188.205.167 |
Bart Fuller & james Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln Street Ruthven, IA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-09 |
James Fuller |
goffins@ruthventel.com |
Ruthven |
Pal Alto |
Iowa |
Kathryn Kelley |
Janice Henningsen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
Palo Alto |
Iowa |
Kathryn Kelley |
Janice Henningsen |
Signed |
1767 |
2023-07-28 14:31 |
Anonymous (not verified) |
94.188.207.229 |
Kleckner Backhoe Service |
Proprietorship |
1302 S 1st St, Osage, IA 50461 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-28 |
Tracy S Kleckner |
terridkleckner@hotmail.com |
Osage |
Mitchell |
Iowa |
Robin Tabbert |
Jeannie Lemke |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
L R Falk Construction Co |
jeannie@lrfalk.com |
Dump Truck Hauler |
Osage |
Mitchell |
Iowa |
Robin Tabbert |
Jeannie Lemke |
Signed |
472 |
2021-04-13 10:58 |
Anonymous (not verified) |
65.103.82.36 |
Scrap And More |
Proprietorship |
1303 W Linn St. Marshalltown, IA. 50158 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-05-01 |
Travis Bachman |
na@yahoo.com |
marshalltown |
marshall |
IA |
sarah |
Tami |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Bachman |
na@yahoo.com |
owner |
marshalltown |
marsahll |
IA |
sara |
tami |
Signed |
1389 |
2022-12-11 12:36 |
Anonymous (not verified) |
24.149.1.5 |
Project Fix It LLC |
Limited Liability Company |
1303 Washington Street Cedar Falls 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. |
2022-12-12 |
Adam L Reiter |
adam.reiter@projectfixit.net |
Cedar Falls |
IA |
United States |
Jennifer Reiter |
Logan Reiter |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Project Fix It |
adam.reiter@projectfixit.net |
Owner |
Cedar Falls |
IA |
United States |
Jennifer Reiter |
Logan Reiter |
Signed |
389 |
2021-02-10 13:59 |
Anonymous (not verified) |
173.24.190.134 |
Shamrock Lanes, LLC |
Limited Liability Company |
1304 Broadway, PO Box 304, 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. |
2021-02-03 |
Cindy Flannegan |
cindylou1964@hotmail.com |
Emmetsburg |
Palo Alto |
Iowa |
Michael Flannegan |
Laura Sidles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cindy Flannegan |
cindylou1964@hotmail.com |
Member of LLC |
Emmetsburg |
Palo Alto |
Iowa |
Michael Flannegan |
Laura Sidles |
Signed |
1210 |
2022-07-18 08:15 |
Anonymous (not verified) |
173.22.187.234 |
Cardinal Rule Handyman Services, LLC |
Limited Liability Company |
1304 E 10th St S, Newton, IA 50208 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-18 |
James Andrew Dunlap |
cardinarulehandyman@gmail.com |
Newton |
Jasper |
Iowa |
Jacinda Marie Dunlap |
James Thornton Dunlap |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Andrew Dunlap |
cardinalrulehandyman@gmail.com |
I am the authorized agent |
Newton |
Jasper |
Iowa |
Jacinda Marie Dunlap |
James Thornton Dunlap |
Signed |
783 |
2021-12-08 10:25 |
Anonymous (not verified) |
173.31.148.43 |
Nick Larsen |
Proprietorship |
1305 7th St. Milford, IA 51351 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-08 |
Nick Larsen |
larsennick77@gmail.com |
Milford |
Dickinson |
IA |
JOSEPH THOMAS LORING |
Kristine Ann Walker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nick Larsen |
joel@walkerinsuranceia.com |
Self |
Milford |
Dickinson |
IA |
JOSEPH THOMAS LORING |
Kristine Ann Walker |
Signed |
1248 |
2022-08-09 11:29 |
Anonymous (not verified) |
166.181.82.131 |
Kelly Kellogg |
Proprietorship |
1305 N 1st st apt 16 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-09 |
Kelly |
Kkell0223@gmail.com |
Indianola |
Warren |
Iowa |
Kelly Kellogg |
Amy Kellogg |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Royal flooring |
workorders@shoproyalflooring.com |
Employee |
Urbandale |
Polk |
Iowa |
Amy |
Kelly |
Signed |
1249 |
2022-08-09 14:14 |
Anonymous (not verified) |
166.181.82.131 |
Kelly Kellogg |
Proprietorship |
1305 N 1st st apt 16 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-09 |
Kelly Kellogg |
Kkell0223@gmail.com |
Indianola |
Warren |
Iowa |
Kelly Kellogg |
Amy Kellogg |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kelly's Flooring |
Kkell0223@gmail.com |
Myself |
1305 N 1st st apt 16 |
Warren |
Iowa |
Kelly Kellogg |
Amy Kellogg |
Signed |
742 |
2021-11-11 15:14 |
Anonymous (not verified) |
72.13.16.172 |
JACOB WESLEY JOHNSON |
Proprietorship |
1306 BAXTER AVENUE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-11-18 |
JACOB WESLEY JOHNSON |
dave@allseasonstrucking.com |
FAIRBANK |
BUCHANAN |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JACOB WESLEY JOHNSON |
dave@allseasonstrucking.com |
PRESIDENT |
FAIRBANK |
BUCHANAN |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
1135 |
2022-05-31 12:06 |
Anonymous (not verified) |
174.215.227.133 |
Plagman Transportation |
Limited Liability Company |
1306 Main St, Adel, Ia. 50003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Ryan Plagman |
rplagman@gmail.com |
Adel |
Dallas |
Ia |
Chris Christensen |
Jack Ruby |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Plagman |
rplagman@gmail.com |
Same |
Adel |
Dallas |
Ia |
Chris Christensen |
Jack Ruby |
Signed |
626 |
2021-08-31 11:39 |
Anonymous (not verified) |
166.181.81.253 |
Birds landscape maintenance LLC |
Limited Liability Company |
1307 w 4th st south |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-31 |
Michael Alan bird |
birdslawn@hotmail.com |
Newton |
Jasper |
Iowa |
Jeff Dennis carder |
Dustin James bos |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Alan bird |
birdslawn@hotmail.com |
Same - owner |
Newton |
Jasper |
Iowa |
Jeff Dennis carder |
Dustin James bos |
Signed |
1902 |
2023-11-10 08:45 |
Anonymous (not verified) |
94.188.207.226 |
Huff Construction LLC |
Limited Liability Company |
1309 Business 30 Sw, Mount Vernon, IA 52314 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-10 |
Jason Huff |
huff.jasonm@gmail.com |
Mount Vernon |
IA |
United States |
Katie Huff |
Van Huff |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jason Huff |
huff.jasonm@gmail.com |
Owner |
Mount Vernon |
IA |
United States |
Katie Huff |
Van Huff |
Signed |
2040 |
2024-02-08 10:35 |
Anonymous (not verified) |
94.188.207.226 |
Storm Pro Solution |
Limited Liability Company |
1309 Coffeen Sheridan,wy 82801 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Candis Henderson |
Cneal@stormprosolution.com |
Broadview |
Chicago |
Illinois |
Chester Neal |
Eric Henderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Candis Henderson |
Cneal@stormprosolution.com |
Self |
Broadview |
Chicago |
Illinois |
Chester neal |
Eric Henderson |
Signed |
2222 |
2024-05-13 11:12 |
Anonymous (not verified) |
94.188.205.176 |
Fresh Painting LLC |
Limited Liability Company |
1310 5th Ave, 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. |
2023-05-13 |
Luke Stougard |
freshpaintingdsm@gmail.com |
Des Moines |
Polk |
Iowa |
Adam Bogi |
Lance Webster |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luke Stougard |
freshpaintingdsm@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Adam Bogi |
Lance Webster |
Signed |
1066 |
2022-04-22 11:17 |
Anonymous (not verified) |
50.83.107.151 |
Delos Steward |
Proprietorship |
1310 w Main Street Marshalltown iowa 50158 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-22 |
Delos Lyle Steward |
LDSPlastering2020@gmail.com |
Marshalltown |
Marshall |
Iowa |
Chris Hart |
Jody Steward |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LDS Plastering |
ldsplastering2020@gmail.com |
Owner |
Marshalltown |
Marshall |
Iowa |
Chris Hart |
Jody Steward |
Signed |
589 |
2021-07-28 16:09 |
Anonymous (not verified) |
97.125.35.240 |
Sotero Alonso Calderon Velasquez |
Proprietorship |
1312 Idaho 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. |
2021-07-26 |
Sotero Alonso Calderon Velazquez |
deb@piciowa.com |
Des Moines |
Polk |
Iowa |
Debra Stratton |
Martin Pinon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sotero Alonso Calderon Velazquez |
deb@piciowa.com |
subcontractor |
Des MOines |
Polk |
Iowa |
Debra Stratton |
Martin Pinon |
Signed |
1850 |
2023-09-20 16:28 |
Anonymous (not verified) |
94.188.207.225 |
JB DOCK SERVICE |
Limited Liability Company |
1313 34TH ST SPIRIT LAKE, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-20 |
JONATHON BRUNSVOLD |
jbdockservice@gmail.com |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JONATHON BRUNSVOLD |
jbdockservice@gmail.com |
SELF |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
468 |
2021-04-12 14:54 |
Anonymous (not verified) |
173.27.224.230 |
PCI Turf LLC |
Limited Liability Company |
1313 N Grant St. Knoxville, IA 50138 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-12 |
Ryan Trout |
rtrout22@yahoo.com |
Knoxville |
Marion |
Iowa |
Joseph Durham |
Carson Peterson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Trout |
pci.turf@yahoo.com |
Self- owner/operator |
Knoxville |
Marion |
Iowa |
Joseph Durham |
Carson Peterson |
Signed |
758 |
2021-11-19 15:12 |
Anonymous (not verified) |
184.80.177.137 |
Upper Room, LLC |
Limited Liability Company |
1314 9th St SE - Dyersville, IA 52040 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-19 |
Keith McCarraher |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
757 |
2021-11-19 15:11 |
Anonymous (not verified) |
184.80.177.137 |
Upper Room, LLC |
Limited Liability Company |
1314 9th St SE -Dyersville, 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. |
2021-11-19 |
DeAnne M McCarraher |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
agent |
Dyersville, IA |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
565 |
2021-07-08 13:42 |
Anonymous (not verified) |
173.25.132.255 |
Communications Construction Services LLC |
Limited Liability Company |
1315 East 38th 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. |
2021-07-08 |
John McCann Jr |
communicationconstructionllc@gmail.com |
Des Moines |
IA |
United States |
Laura McCann |
David Garza |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Laura McCann |
communicationconstructionllc@gmail.com |
spouse |
Des Moines |
IA |
United States |
John J McCann Jr |
David Christopher Garza III |
Signed |
887 |
2022-02-03 14:05 |
Anonymous (not verified) |
173.27.49.231 |
Jade Mallicoat coaching |
Limited Liability Company |
1318 se linn 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. |
2022-02-03 |
Jade Mallicoat |
jade.mallicoat@gmail.com |
Boone |
Boone |
Iowa |
Cord Anderson |
Mike Anderson |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jade mallicoat |
jade.mallicoat@gmail.com |
Myself |
Boone |
Boone |
Iowa |
Cord Anderson |
Mike Anderson |
Signed |
2091 |
2024-03-12 15:23 |
Anonymous (not verified) |
94.188.205.166 |
Shelley onnen |
Proprietorship |
1319 West 2nd Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-12 |
Shelley L Onnen |
Shelleyonnen47@gmail.com |
PERRY |
IA |
United States |
Matthew Dean Rote |
Jerica Renae Wiborg |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shelley L Onnen |
Shelleyonnen47@gmail.com |
Self |
PERRY |
IA |
United States |
Matthew Dean Rote |
Jerica Renae Wiborg |
Signed |
430 |
2021-03-10 13:01 |
Anonymous (not verified) |
192.30.185.142 |
Trey LaGois Construction |
Proprietorship |
132 W Cedar St, Hinton, IA 51024 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-10 |
Trey LaGois |
treylagois2015@gmail.com |
Hinton |
Plymouth |
IA |
Katie Jenks |
Nate Blaeser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Trey LaGois |
treylagois2015@gmail.com |
Owner |
Hinton |
Plymouth |
IA |
Katie Jenks |
Nate Blaeser |
Signed |