1885 |
2023-10-29 08:05 |
Anonymous (not verified) |
94.188.207.223 |
MB Radon Services |
Limited Liability Company |
13206 State Hwy 2, Lamoni, Iowa, 50140 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-29 |
Kyle Ramaeker |
raymaker83@gmail.com |
LAMONI |
IA |
United States |
Adam Boge |
Lance Webster |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kyle Ramaeker |
raymaker83@gmail.com |
Owner/Operator |
LAMONI |
IA |
United States |
Adam Boge |
Lance Webster |
Signed |
715 |
2021-11-05 11:27 |
Anonymous (not verified) |
209.252.172.87 |
Ken Clifford |
Proprietorship |
132121st Ave SW Cedar Rapids, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-18 |
Ken Clifford |
ken40406108@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ken Clifford |
ken40406108@gmail.com |
Self Employer |
Cedar Rapids |
Linn |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
436 |
2021-03-16 13:37 |
Anonymous (not verified) |
141.193.221.33 |
Custom Applicationz |
Partnership |
13220 Hwy S70 Plano, IA 52581 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-16 |
Zebulun Joiner |
joinerconst@gmail.com |
Plano |
Appanoose |
IA |
Danielle Joiner |
Zebulun Joiner |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Danielle Joiner |
joinerconst@gmail.com |
Self/Wife of Partner |
Plano |
Appanoose |
IA |
Zebulun Joiner |
Danielle Joiner |
Signed |
2204 |
2024-05-06 18:56 |
Anonymous (not verified) |
94.188.205.168 |
Jim saukko |
Proprietorship |
13232 nw 30 th 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. |
2024-05-05 |
Jim Saukko |
saukkogt500@gmail.com |
Polk city |
IA |
United States |
Dawn brown |
Kirk moser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jim Saukko |
saukkogt500@gmail.com |
Self |
Polk city |
IA |
IA |
Dawn brown |
Kirk moser |
Signed |
1749 |
2023-07-17 10:52 |
Anonymous (not verified) |
94.188.205.175 |
Zenon Loreto |
Proprietorship |
1324 E 29th St Des Moines, IOwa 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-17 |
Zenon Loreto |
deb@piciowa.com |
Des Moines |
Polk |
Iowa |
Inspro in 2019 |
Inspro in 2019 |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Zenon Loreto |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Inspro in 2019 |
Inspro in 2019 |
Signed |
990 |
2022-03-21 15:18 |
Anonymous (not verified) |
174.192.80.32 |
Chris Binns |
Proprietorship |
1324 Grand Ave 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. |
2022-03-21 |
Christ Binns |
christophersbinns@gmail.com |
Davenpory |
Scott |
IA |
Adam Coleman |
Rose Snyder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chris Binns |
christophersbinns@gmail.com |
Same |
Davenport |
Scott |
IA |
Adam Coleman |
Rose Snyder |
Signed |
992 |
2022-03-21 19:42 |
Anonymous (not verified) |
174.192.66.11 |
Christopher Binns |
Proprietorship |
1324 Grand Ave, 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. |
2022-03-21 |
Christopher Binns |
christophersbinns@gmail.com |
Davenport |
Scott |
IA |
Adam Coleman |
Rose Snyder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christopher Binns |
christophersbinns@gmail.com |
same |
Davenport |
Scott |
IA |
Adam Coleman |
Rose Snyder |
Signed |
2165 |
2024-04-19 14:05 |
Anonymous (not verified) |
94.188.207.225 |
Apex Striping LLC |
Limited Liability Company |
1325 Western Ave, cedar Falls, IA. 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-19 |
Chaz Ernest Torres |
admin@apexstripingia.com |
Cedar Falls |
Blackhawk |
Iowa |
Theresa Jo Torres |
Eloy James Torres |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chaz Ernest Torres |
admin@apexstripingia.com |
Self |
Cedar Falls |
Blackhawk |
Iowa |
Theresa Jo Torres |
Eloy James Torres |
Signed |
474 |
2021-04-13 12:09 |
Anonymous (not verified) |
65.103.82.36 |
Helfrich Construction |
Proprietorship |
1327 Garnet St. Burlington 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. |
2019-04-29 |
Tad Helfrich |
littlet20012001@yahoo.com |
Burlington |
Des Moines |
IA |
Teresa Helfrich |
Ron Helfrich |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tad Helfrich |
littlet20012001@yahoo.com |
owner |
Burlington |
Des Moines |
IA |
Teresa Helfrich |
Ron Helfrich |
Signed |
1477 |
2023-02-23 11:45 |
Anonymous (not verified) |
94.188.205.166 |
Earl Woods DBA Solar Solutions |
Proprietorship |
1328 42nd 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. |
2023-02-23 |
Earl Woods |
solarsolutions_1@msn.com |
Des Moines |
Polk |
Iowa |
Terrie Woods |
Tracy Day |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Earl Woods |
solarsolutions_1@msn.com |
wife |
Des Moines |
Polk |
IA |
Terrie Woods |
Tracy Day |
Signed |
829 |
2022-01-11 11:03 |
Anonymous (not verified) |
173.22.78.156 |
Marr Arnold Planning, LLC |
Limited Liability Company |
1328 California Ave, Ames, IA 50014 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-11 |
Summer Marr |
summer@marrarnoldplanning.com |
Ames |
Story |
IA |
Beth Skluzacek |
Kris Evans |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Summer Marr |
summer@marrarnoldplanning.com |
owner |
Ames |
Story |
IA |
Beth Skluzacek |
Kris Evans |
Signed |
828 |
2022-01-11 10:34 |
Anonymous (not verified) |
74.215.151.63 |
Marr Arnold Planning |
Limited Liability Company |
1328 California Ave. Ames Iowa 50014 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-11 |
Sarah Arnold |
sarahkarnold@gmail.com |
Cincinnati |
Hamilton |
Ohio |
April Humphreys |
Amy Burns |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sarah Arnold |
sarah@marrarnoldplanning.com |
Self |
Cincinnati |
Hamilton |
Ohio |
Amy Burns |
April Humphreys |
Signed |
1828 |
2023-09-06 14:43 |
Anonymous (not verified) |
94.188.205.177 |
Des Moines Smart Solutions LLC. |
Proprietorship |
1329 56th st, Des Moines, IA 50311, 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. |
2023-09-06 |
Denzel Colocho |
alejandro_colcho@yahoo.com |
Des Moines, IA |
Polk |
Iowa |
Jordan Nisiewicz |
Jordan Loyd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Clay |
MO |
Jordan Loyd |
Charles Wood |
Signed |
1821 |
2023-08-29 10:11 |
Anonymous (not verified) |
94.188.205.169 |
Des Moines Smart Solutions LLC |
Limited Liability Company |
1329 56th St., Des Moines, IA 50311 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-29 |
Denzel Colocho |
alejandro_colocho@yahoo.com |
Des Moines |
Polk |
Iowa |
Steve Webb |
Austin Kelderman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Des Moines Smart Solutions LLC |
alejandro_colocho@yahoo.com |
Owner |
Des Moines |
Polk |
Iowa |
Steve Webb |
Austin Kelderman |
Signed |
1011 |
2022-03-28 10:25 |
Anonymous (not verified) |
207.199.231.172 |
Brian Carmer |
Proprietorship |
133 S Iowa Ave, Ottumwa, IA 52501 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-28 |
Brian Carmer |
b_carmer@yahoo.com |
Ottumwa |
Wapello |
Iowa |
James Anderson |
Ashley Bryan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Carmer |
B_Carmer@yahoo.com |
Self |
Ottumwa |
Wapello |
Iowa |
James Anderson |
Ashley Bryan |
Signed |
1825 |
2023-08-30 11:16 |
Anonymous (not verified) |
94.188.207.225 |
Quad City Glass |
Proprietorship |
1330 N Harrison St. Davenport, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-30 |
Jacob Brown |
quadcityglass@gmail.com |
Davenport |
Scott |
IOWA |
na |
na |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Quad City Glass |
Quadcityglass@gmail.com |
employee |
Davenport |
Scott |
IOWA |
na |
na |
Signed |
1432 |
2023-01-25 16:52 |
Anonymous (not verified) |
174.228.33.48 |
Thermal Tight Insulators |
Proprietorship |
1331 Linden Road |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-25 |
Shawn Carter |
steelershawn@gmail.com |
Harlan |
Iowa |
United States |
Barbara Carter |
McKenzie carter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shawn Carter |
steelershawn@gmail.com |
Self |
Harlan |
Iowa |
United States |
Barbara Carter |
McKenzie carter |
Signed |
1992 |
2024-01-18 21:51 |
Anonymous (not verified) |
94.188.205.175 |
NB Tile |
Proprietorship |
13310 NE 112th 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. |
2024-01-18 |
Niles Michael James Bailey |
NBtiledesign@gmail.com |
Maxwell |
IA |
United States |
Kevin Orr |
Sydney Paustian |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Niles Michael James Bailey |
NBtiledesign@gmail.com |
Owner |
Mawell |
Polk |
Iowa |
Kevin Orr |
Sydney Paustian |
Signed |
74 |
2020-02-24 15:00 |
Anonymous (not verified) |
97.64.133.18 |
Sky Roofing LLC |
Partnership |
1332 Idaho 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. |
2020-01-01 |
Ramiro Jurado Gomez |
Liberty21424@gmail.com |
Des Moines |
Polk |
IA |
Valerie Cramer |
David Murray |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Valerie Cramer |
cramerlaw@halousa.com |
Attorney |
Des Moines |
Polk |
Iowa |
David Murray |
Sara McGinnis |
Signed |
75 |
2020-02-24 15:03 |
Anonymous (not verified) |
97.64.133.18 |
Sky Roofing LLC |
Partnership |
1332 Idaho 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. |
2020-01-01 |
Ramiro Jurado Bucio |
Liberty21424@gmail.com |
des moines |
Polk |
Iowa |
Valerie Cramer |
David Murray |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Valerie Cramer |
cramerlaw@halousa.com |
Attorney |
Des Moines |
Polk |
Iowa |
David Murray |
Sara McGinnis |
Signed |
76 |
2020-02-24 15:05 |
Anonymous (not verified) |
97.64.133.18 |
Sky Roofing |
Partnership |
1332 Idaho 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. |
2020-01-01 |
Angel Jurado |
Liberty21424@gmail.com |
des moines |
Polk |
Iowa |
Valerie Cramer |
David Murray |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cramer Law PLC |
cramerlaw@halousa.com |
Attorney |
Polk |
Polk |
Iowa |
Sara Mc Ginnis |
David Murray |
Signed |
77 |
2020-02-24 15:07 |
Anonymous (not verified) |
97.64.133.18 |
Sky Roofing LLC |
Partnership |
1332 Idaho 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. |
2020-01-01 |
Victor Jurado |
Liberty21424@gmail.com |
des moines |
Polk |
Iowa |
David Murray |
Valerie Cramer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cramer Law PLC |
Liberty21424@gmail.com |
Attorney |
DES MOINES |
POlk |
Iowa |
David Murray |
Sara McGinnis |
Signed |
1963 |
2023-12-18 14:45 |
Anonymous (not verified) |
94.188.207.227 |
Elite Excavation Services |
Limited Liability Company |
13335 Amber Rd X44 Anamosa 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. |
2023-12-18 |
Dalton Starn |
eliteexcavationservices97@gmail.com |
Anamosa |
Jones |
Iowa |
Chase miller |
Nathan Decker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dalton Starn |
eliteexcavationservices97@gmail.com |
Owner |
Anamosa |
Jones |
Iowa |
Chase miller |
Nathan decker |
Signed |
1608 |
2023-04-26 11:51 |
Anonymous (not verified) |
94.188.205.167 |
Jesus Lozano |
Proprietorship |
1334 E 16th st Des Moines Iowa 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. |
2023-10-26 |
Jesus Lozano |
Jesuslozano0086@icloud.com |
Des Moines |
Polk |
Iowa |
Sheanah Wright |
Derek Mullins |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jesus Lozano |
Jesuslozano0086@icloud.com |
Owner |
Des Moines |
Polk |
Iowa |
Sheanah Wright |
Derek Mullins |
Signed |
1001 |
2022-03-23 10:37 |
Anonymous (not verified) |
104.201.100.158 |
Joel Jacobsen |
Proprietorship |
1337 S 7th 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. |
2022-03-23 |
Joel Jacobsen |
jjacobsen@phillipsstafford.com |
Adel |
Iowa |
United States |
Luke Peterson |
Luke van Roekel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joel Jacobsen |
jjacobsen@phillipsstafford.com |
Self |
Adel |
Iowa |
United States |
Luke Peterson |
Luke Van Roekel |
Signed |
1700 |
2023-06-22 14:53 |
Anonymous (not verified) |
94.188.205.166 |
James Trotter |
Limited Liability Company |
1341 Cachelin Dr Carter Lake IA 51510 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
James Trotter |
trotterwizard@gmail.com |
Carter Lake |
Pottawattamie |
IA |
Shelby Schultz |
Elora Trotter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Trotter |
trotterwizard@gmail.com |
Self |
Carter Lake |
Pottawattamie |
IA |
Shelby Schultz |
Elora Trotter |
Signed |
1701 |
2023-06-22 15:03 |
Anonymous (not verified) |
94.188.207.228 |
Midwest Teleworks |
Limited Liability Company |
1341 Cachelin Dr Carter Lake IA 51510 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
James Trotter |
trotterwizard@gmail.com |
Carter Lake |
Pottawattamie |
IA |
Shelby Schultz |
Elora Trotter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Trotter |
trotterwizard@gmail.com |
Owner |
Carter Lake |
Pottawattamie |
IA |
Shelby Schultz |
Elora Trotter |
Signed |
750 |
2021-11-16 12:34 |
Anonymous (not verified) |
172.58.83.130 |
Austin Carlson |
Proprietorship |
1341 iron city avenue atalissa 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. |
2021-11-16 |
Austin Carlson |
toppeakconstruction@gmail.com |
Atalissa |
Muscating |
Iowa |
Jordan Nisiewicz |
Sam Apponey |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jorden Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Jackson |
Missouri |
Jordan Nisiewicz |
Sam Apponey |
Signed |
279 |
2020-10-19 08:02 |
Anonymous (not verified) |
66.188.136.150 |
Keith McNair |
Proprietorship |
13436 Silver Brook Dr. Pickerington, OH 43147 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-16 |
Keith McNair |
kschumacher@tricorinsurance.com |
Pickerington |
Fairfield |
OH |
Nancy Wortley |
Russell Masartis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Keith McNair |
kschumacher@tricorinsurance.com |
Same |
Pickerington |
Fairfield |
OH |
Nancy Wortley |
Russell Masartis |
Signed |
540 |
2021-06-08 21:40 |
Anonymous (not verified) |
50.83.39.243 |
Brightland Appraisal Group |
Limited Liability Company |
1348 Rolling Glen Dr. 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. |
2021-06-08 |
Eric Lamp |
eric.lamp@brightlandappraisal.com |
Marion |
Linn |
Iowa |
Sarah Lamp |
Linda Lamp |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Eric Allen Lamp |
eric.lamp@brightlandappraisal.com |
Self |
Marion |
Linn |
Iowa |
Sarah Lamp |
Linda Lamp |
Signed |
303 |
2020-10-31 13:11 |
Anonymous (not verified) |
173.17.230.149 |
Absolute Construction |
Limited Liability Partnership |
135 main street, Carlisle, IA 50047 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-31 |
James Nelson |
jamesnelson1983@gmail.com |
Carlisle |
Warren |
Iowa |
Joe Simpson |
Alex Vanderbeek |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Nelson |
jamesnelson1983@gmail.com |
self |
Carlisle |
Warren |
Iowa |
Joe Simpson |
Alex Vanderbeek |
Signed |
1022 |
2022-03-30 15:08 |
Anonymous (not verified) |
216.51.227.123 |
Elite Business Cleaning |
Limited Liability Company |
1350 Kennel Ct Unit C2 north liberty IA 52317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-30 |
rogelio morales ortega |
info@elitebusinesscleaning.com |
iowa city |
johnson |
Iowa |
alma rosa ortega |
john Spencer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Elite Business Cleaning |
info@elitebusinesscleaning.com |
Ownerr |
iowa city |
johnson |
iowa |
Alma Rosa Ortega |
John Spender |
Signed |
1307 |
2022-09-14 13:40 |
Anonymous (not verified) |
216.51.227.123 |
elite business ckeaning |
Proprietorship |
1350 kennel ct unit c2 north liberty IA 52317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-14 |
rogelio morales ortega |
info@elitebusinesscleaning.com |
iowa city |
johnson |
iowa |
cesar morales ortega |
alma rosa perez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
elite busibess cleaning |
info@elitebusinesscleaning.com |
president |
north liberty |
johnson |
iowa |
karina aguilar |
jessica lee |
Signed |
2001 |
2024-01-26 10:41 |
Anonymous (not verified) |
94.188.207.225 |
4 Sons Splicing & Activation |
Proprietorship |
13510 W Brazos Bend Dr, Needville, TX 77461-9525 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-26 |
John Kevin Steil |
foursons1990@steil.org |
Needville |
Ft. Bend |
Texas |
Dennis Reeves Oliver |
Stephanie Ranae Oliver |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Helen Frances Steil |
foursons1990@steil.org |
Spouse |
Needville |
Ft. Bend |
Texas |
Dennis Reeves Oliver |
Stephanie Ranae Oliver |
Signed |
1667 |
2023-05-29 22:31 |
Anonymous (not verified) |
94.188.207.226 |
All J Acres |
Limited Liability Company |
13522 120th Ave, Ottumwa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-26 |
Jonathan Bunt |
jonbunt@gmail.com |
Ottumwa |
Wapello |
IA |
James Williamson |
James Ash |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jonathan Bunt |
jonbunt@gmail.com |
Self |
Ottumwa |
Wapello |
IA |
James Williamson |
James Ash |
Signed |
551 |
2021-06-29 09:18 |
Anonymous (not verified) |
72.168.160.90 |
BERNARD WATERBECK |
Limited Liability Company |
1353 280TH STREET, GARWIN, IOWA 50632 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-29 |
BERNARD WATERBECK |
garwinacres2012@hotmail.com |
GARWIN |
TAMA |
IOWA |
DEAN KELLER |
CESAR MARROQUIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
BERNARD WATERBECK |
garwinacres2012@hotmail.com |
SAME PERSON |
GARWIN |
TAMA |
IOWA |
DEAN KELLER |
CESAR MARROQUIN |
Signed |
958 |
2022-03-08 20:17 |
Anonymous (not verified) |
50.82.39.158 |
Ramos Drywall |
Limited Liability Company |
1355 Ozark Ridge, Coralville, IA 52241 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-03-08 |
Carlos Rene Ramos Martinez |
carlosramos2345@gmail.com |
Coralville |
Iowa |
United States |
Breanna Barragan |
Eliseo Tapia JR. |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Carlos Rene Ramos Martinez |
carlosramos2345@gmail.com |
N/A- Same Person |
Coralville |
Johnson County |
IA |
Breanna Barragan |
Eliseo Tapia JR. |
Signed |
1995 |
2024-01-23 15:08 |
Anonymous (not verified) |
94.188.205.167 |
Spencer Abbott |
Proprietorship |
1358 170th Ave, Murray Iowa 50174 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-23 |
Spencer Abbott |
sabbott1800@gmail.com |
Murray |
Clarke |
Iowa |
Juanita Yutzy |
Elaine Lee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Spencer Abbott |
sabbott1800@gmail.com |
sole proprietor |
Murray |
Clarke |
Iowa |
Juanita Yutzy |
Elaine Lee |
Signed |
467 |
2021-04-10 12:21 |
Anonymous (not verified) |
24.252.54.168 |
Dave and Nancy Preucil Inc. |
Proprietorship |
13585 Clearview Lane |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-10 |
Domenico Zurini II |
davesspeedwaydz@gmail.com |
Council Bluffs |
IA |
United States |
Irven Saar II |
Jeffrey Hanke |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Barbi Zurini |
bzurini@gmail.com |
Wife |
Council Bluffs |
IA |
United States |
Irven Saar II |
Jeffrey Hanke |
Signed |
690 |
2021-10-26 14:23 |
Anonymous (not verified) |
65.144.174.26 |
Santiago Rojas |
Proprietorship |
1359 22nd st Des Moines, IA 50311 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-26 |
Santiago Rojas |
rojassr09@gmail.com |
Des Moines |
Polk |
Iowa |
David Rojas |
Beatriz Hernandez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Santiago Rojas |
rojassr09@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
David Rojas |
Beatriz Hernandez |
Signed |
2055 |
2024-02-23 14:54 |
Anonymous (not verified) |
94.188.207.224 |
Neil Vonnahme |
Proprietorship |
13628 220th St., Arcadia, Iowa, 51430 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-20 |
Neil Vonnahme |
neilvonnahme@gmail.com |
Arcadia |
Carroll |
Iowa |
Kyle Klein |
Brenda Klein |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Neil Vonnahme |
neilvonnahme@gmail.com |
Self |
Arcadia |
Carroll |
Iowa |
Kyle Klein |
Brenda Klein |
Signed |
469 |
2021-04-12 16:49 |
Anonymous (not verified) |
65.103.82.36 |
Stice Construction |
Proprietorship |
13723 140th st W |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-07-22 |
Alex Stice |
Astice17@hotmail.com |
Taylor Ridge |
Rock Island |
IL |
Ashley Stice |
JIm Stice |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alex Stice |
astice17@hotmail.com |
self |
taylor ridge |
rock island |
il |
Ashley stice |
Jim Stice |
Signed |
2186 |
2024-04-28 11:12 |
Anonymous (not verified) |
94.188.205.168 |
John Martin |
Proprietorship |
1378 60th avenue Blue Grass 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. |
2024-04-28 |
John D Martin |
martinflooring@netzero.com |
Blue Grass |
Muscatine |
Iowa |
John D Martin |
John D Martin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John D Martin |
martinflooring@netzero.com |
Owner |
Blue Grass |
Muscatine |
Iowa |
John D Martin |
John D Martin |
Signed |
1915 |
2023-11-21 04:06 |
Anonymous (not verified) |
94.188.207.225 |
Advanced Foam Systems |
Limited Liability Company |
1378 Midway Ave Tripoli IA 50676 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-18 |
Randy Block |
advancedfoamsystems@yahoo.com |
Tripoli |
Bremer |
Iowa |
Linda Block |
Brady Block |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Randy Block |
advancedfoamsystems@yahoo.com |
Me |
Tripoli |
Bremer |
Iowa |
Linda block |
Brady block |
Signed |
926 |
2022-02-17 15:20 |
Anonymous (not verified) |
166.181.83.68 |
Staley Trucking LLC |
Limited Liability Company |
1388 140th 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. |
2022-02-17 |
Travis Staley |
staleyracing121@gmail.com |
Hampton |
Franklin |
IA |
Tyler Staley |
Jeff Staley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Staley |
staleyracing121@gmail.com |
President |
Hampton |
Franklin |
IA |
Tyler Staley |
Jeff Staley |
Signed |
490 |
2021-04-20 14:06 |
Anonymous (not verified) |
173.18.16.129 |
frey construction |
Limited Liability Company |
1388 205th 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. |
2021-04-20 |
Dana Frey |
dingaf37@yahoo.com |
Creston |
Union |
Iowa |
Lesa Reeves |
Kelly Coluzzi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dana Frey |
dingaf37@yahoo.com |
owner |
Creston |
Union |
Iowa |
Lesa Reeves |
Kelly Coluzzi |
Signed |
1998 |
2024-01-25 16:18 |
Anonymous (not verified) |
94.188.205.168 |
Faith and Trust Soulutions LLC |
Limited Liability Company |
139 37th Street NE Suite # 2 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-25 |
Marie Moore |
faithandtrustsoulutionsllc@gmail.com |
Cedar Rapids |
Iowa |
United States |
Arthur Barbine |
Arthur Barbine |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Arthur Barbine |
faithandtrustsoulutionsllc@gmail.com |
Friend |
Cedar Rapids |
Iowa |
United States |
Arthur Barbine |
Arthur Barbine |
Signed |
1781 |
2023-08-03 21:23 |
Anonymous (not verified) |
94.188.205.166 |
Ron Peiffer Machine |
Limited Liability Company |
139 S 1st St Harpers Ferry, Ia 52146 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-03 |
Ron Peiffer |
ron@rpeiffer.com |
Harpers Ferry |
Allamakee |
Iowa |
Marie Burington |
Cassie Bakke |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ron Peiffer |
ron@rpeiffer.com |
myself- SOLE PROPRIETOR |
Harpers Ferry |
Allamakee |
Iowa |
Marie Burington |
Cassie Bakke |
Signed |
1057 |
2022-04-18 12:53 |
Anonymous (not verified) |
204.16.59.10 |
Iowa’s Gutter Specialist LLC |
Limited Liability Company |
1390 Lark Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-18 |
Dustin Halverson |
dh42312695@gmail.com |
Hampton |
IA |
United States |
Heather Halverson |
Michael Halverson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Halverson |
dh42312695@gmail.com |
Owner |
Hampton |
IA |
United States |
Heather Marie Halverson |
Michael Alexander Halverson |
Signed |
1370 |
2022-11-13 19:49 |
Anonymous (not verified) |
174.213.144.30 |
Iowa’s Gutter Specialist |
Limited Liability Company |
1390 Lark Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-21 |
Dustin Halverson |
dh42312695@gmail.com |
Hampton |
IA |
United States |
Patricia Reynolds |
Heather Halverson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Halverson |
dh42312695@gmail.com |
Owner |
Hampton |
IA |
United States |
Patricia Marie Reynolds |
Heather Marie Halverson |
Signed |
1950 |
2023-12-12 12:20 |
Anonymous (not verified) |
94.188.205.168 |
Central Iowa Welding & Repair |
Limited Liability Company |
13913 140th Avenue |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-01 |
Trevor Campbell |
centraliowaweldingrepair@gmail.com |
Indianola |
Warren |
Iowa |
Amber Campbell |
Jake Snow |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Trevor Campbell |
centraliowaweldingrepair@gmail.com |
Owner |
Indianola |
Warren |
Iowa |
Amber Campbell |
Jake Snow |
Signed |
124 |
2020-04-16 12:07 |
Anonymous (not verified) |
96.3.180.122 |
Gold Rush, LLC |
Limited Liability Company |
1395 130TH ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-16 |
Jay Christopher Morrow |
jcmorrow2@hotmail.com |
WAYLAND |
Henry |
IAUS |
chad mitchell |
Jonathan Mitchell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gold Rush, LLC |
jcmorrow2@gmail.com |
Self |
WAYLAND |
Henry |
IAUS |
chad mitchell |
Jonathan Mitchell |
Signed |
189 |
2020-06-16 16:24 |
Anonymous (not verified) |
173.28.58.2 |
Perry Engel |
Proprietorship |
140 2nd Ave NW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-12 |
Perry Engel |
HRSolutionsContracting@gmail.com |
Oelwein |
IA |
United States |
Danette Hager |
Tosha Medina |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Perry Engel |
HRSolutionsContracting@gmail.com |
Self |
Oelwein |
IA |
United States |
Danette Hager |
Tosha Medina |
Signed |
1874 |
2023-10-22 11:54 |
Anonymous (not verified) |
94.188.205.166 |
Midwest UAV LLC |
Limited Liability Company |
1400 15th St SE Bondurant Iowa 50035 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-22 |
Kaleb Thomas Trammell |
kttrammell05@gmail.com |
Bondurant |
Polk |
IA |
Alan Willis |
Danielle Trammell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kaleb Thomas Trammell |
kttrammell05@gmail.com |
Owner |
Bondurant |
Polk |
IA |
Alan Willis |
Danielle Trammell |
Signed |
33 |
2020-01-09 15:57 |
Anonymous (not verified) |
173.28.28.57 |
FALCON PRIDE PROPERTIES LLC |
Limited Liability Company |
1401 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. |
2019-12-13 |
TODD THOMAS |
todd@wimcoach.com |
PARKERSBURG |
BUTLER |
IA |
CHAD CAMPBELL |
ROXANNE KOLDER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
TODD THOMAS |
todd@wimcoach.com |
SELF |
PARKERSBURG |
BUTLER |
IA |
CHAD CAMPBELL |
ROXANNE KOLDER |
Signed |
1403 |
2023-01-03 15:23 |
Anonymous (not verified) |
173.20.50.85 |
Falcon Pride Properties, LLC |
Limited Liability Company |
1401 State Highway 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. |
2022-12-23 |
D. Jay Ellis |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
D. Jay Ellis |
cmins_re@mchsi.com |
Owner |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
1404 |
2023-01-03 15:26 |
Anonymous (not verified) |
173.20.50.85 |
Falcon Pride Properties, LLC |
Limited Liability Company |
1401 State Highway 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. |
2022-12-23 |
Todd Thomas |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Todd Thomas |
cmins_re@mchsi.com |
Owner |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
766 |
2021-11-22 16:19 |
Anonymous (not verified) |
63.229.189.35 |
Tribal Tile, LLC |
Limited Liability Company |
1402 Ithaca Ave, 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. |
2021-11-22 |
Josh Loerzel |
joshloerzel@gmail.com |
Spirit Lake |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Loerzel |
joshloerzel@gmail.com |
Self |
SPIRIT LAKE |
Dickinson |
IA |
Abigail Miles |
Alex Miles |
Signed |
1101 |
2022-05-13 12:55 |
Anonymous (not verified) |
174.199.102.54 |
Daniel Blanco |
Proprietorship |
1403 2nd Ave S |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-13 |
Daniel Blanco |
chindan77@yahoo.com |
Ft Dodge |
Webster |
IA |
Vanessa Blanco |
Elva Castañeda |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Blanco |
chindan77@yahoo.com |
Self |
Ft Dodge |
Webster |
IA |
Vanessa Blanco |
Elva Castañeda |
Signed |
1900 |
2023-11-09 23:24 |
Anonymous (not verified) |
94.188.207.224 |
Daniel Blanco |
Proprietorship |
1403 2nd Ave S |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-09 |
Daniel Blanco |
chindan77@yahoo.com |
Fort Dodge |
IA |
United States |
Vanessa Blanco |
Jorge Blanco |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Blanco |
chindan77@yahoo.com |
Self |
Fort Dodge |
IA |
United States |
Elva Castañeda |
Vanessa Blanco |
Signed |
641 |
2021-09-17 09:16 |
Anonymous (not verified) |
72.255.121.118 |
Osman Gonzalez-Sarceno |
Proprietorship |
1403 Aspen Dr Adel, 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. |
2021-09-17 |
Osman Gonzalez-Sarceno |
workorders@shoproyalflooring.com |
Des Moines |
Polk |
IA |
Melissa Bolanos |
Brianna Fuller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Osman Gonzalez-Sarceno |
workorders@shoproyalflooring.com |
Owner |
Des Moines |
Polk |
Iowa |
Melissa Bolanos |
Brianna Fuller |
Signed |
693 |
2021-10-26 15:03 |
Anonymous (not verified) |
65.144.174.26 |
Diamante Tile |
Proprietorship |
1403 Aspen Dr 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. |
2021-10-26 |
Octavio Bermudez |
aerosobo@gmail.com |
Des Moines |
Dallas |
Iowa |
Antonia Bermudez |
Sofia Piatt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Octavio Bermudez |
aerosobo@gmail.com |
Owner |
Adel |
Dallas |
Iowa |
Antonia Bermudez |
Sofia Piatt |
Signed |
1375 |
2022-11-18 10:21 |
Anonymous (not verified) |
166.181.87.119 |
Heff Built Construction LLC |
Limited Liability Company |
1403 Kodiak Dr NW Cedar Rapids, IA 52405 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-18 |
Jacob Heffernen |
jheffernen@gmail.com |
Cedar Rapids |
Linn |
IA |
Kyle Reid |
Amanda Frese |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jacob Heffernen |
jheffernen@gmail.com |
N/A |
Cedar Rapids |
Linn |
IA |
Kyle Reid |
Amanda Frese |
Signed |
2013 |
2024-01-31 15:14 |
Anonymous (not verified) |
94.188.205.167 |
Aspen Ridge LLC |
Limited Liability Company |
1404 G Ave Marengo, IA 52301 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-10 |
Jeffrey McKusker |
jeff@mckuskerelectric.com |
Marengo |
Iowa |
Iowa |
Karly Kovar |
Jacob McKusker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lori McKusker |
jeff@mckuskerelectric.com |
Spouse |
Mead |
Weld |
Colorado |
Karly Kovar |
Jacob McKusker |
Signed |
2014 |
2024-01-31 15:17 |
Anonymous (not verified) |
94.188.205.174 |
Aspen Ridge LLC |
Limited Liability Company |
1404 G Avenue |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-10 |
Lori McKusker |
lori@mckuskerelectric.com |
Mead |
Weld |
Colorado |
Karly Kovar |
Jacob McKusker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lori McKusker |
jeff@mckuskerelectric.com |
Self |
Mead |
Weld |
Colorado |
Karly Kovar |
Jacob McKusker |
Signed |
204 |
2020-07-15 11:21 |
Anonymous (not verified) |
63.152.54.222 |
Tim Duggan |
Limited Liability Company |
1405 1st St. SW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-15 |
Timothy M Duggan |
tdc.inc30@gmail.com |
Cedar Rapids |
Iowa |
United States |
Joe Willis |
Andrew Anson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy M Duggan |
tdc.inc30@gmail.com |
President |
Cedar Rapids |
Iowa |
United States |
Joe Willis |
Andrew Anson |
Signed |
473 |
2021-04-13 11:26 |
Anonymous (not verified) |
65.103.82.36 |
Quality Renovation |
Proprietorship |
1406 25th st Moline IL 61265 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-06-21 |
Clarence Marvin Skipton |
marvinthemartien77@gmail.com |
Buffalo |
Scott |
IA |
Jennifer Skipton |
Rose mary Skipton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Clarence Marvin Skipton |
marvinthemartien77@gmail.com |
Owner |
Moline |
Rock Island |
IL |
Jennifer skipton |
rose Skipton |
Signed |
1947 |
2023-12-07 16:01 |
Anonymous (not verified) |
94.188.205.176 |
Reinier Construction LLC |
Limited Liability Company |
1406 Linden Lane |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-07 |
David J Reinier |
reinierconst@aol.com |
Des Moines |
Polk |
IA |
PEGGY A ROHDE |
Douglas E Rohde |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
PEGGY A ROHDE |
dnprohde@msn.com |
Bookkeeper |
Polk City |
Polk |
IA |
Douglas E Rohde |
Stacie L Miller |
Signed |
668 |
2021-10-12 16:11 |
Anonymous (not verified) |
173.18.22.217 |
Mo's Cleaning LLC |
Limited Liability Company |
1412 E 23rd St Des Moines IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-12 |
Melissa Jones |
commcleanwithme123@gmail.com |
Des Moines |
Polk |
IA |
Kelly Coluzzi |
Lesa Reeves |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melissa Jones |
commcleanwithme123@gmail.com |
Owner |
Des Moines |
Polk |
IA |
Kelly Coluzzi |
Lesa Reeves |
Signed |
1243 |
2022-08-04 21:00 |
Anonymous (not verified) |
173.24.221.228 |
Foreman's Tile Creations |
Proprietorship |
1412 Franklin St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-04 |
Sole Proprietor |
fudog4man@gmail.com |
Center Point |
Linn |
IA |
Aaron Foreman |
Aaron Foreman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aaron Foreman |
fudog4man@gmail.com |
I am the Employer |
Center Point |
Linn |
IA |
Aaron Foreman |
Aaron Foreman |
Signed |
587 |
2021-07-26 12:40 |
Anonymous (not verified) |
172.56.7.208 |
Central Iowa Dict Cleaning |
Proprietorship |
1414 Adventureland Dr #4206 Altoona IA 50009 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-26 |
Gary Gallagher |
ductclean@gmail.com |
Altoona |
Polk |
IA |
Meghan Militti |
Todd Nastase |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gary Gallagher |
ductclean@gmail.com |
Self |
Altoona |
Polk |
IA |
Meghan Militti |
Todd Nastase |
Signed |
1788 |
2023-08-07 18:32 |
Anonymous (not verified) |
94.188.205.168 |
Johnson Custom Paint & Design LLC |
Limited Liability Company |
1414 N 9TH 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. |
2023-08-07 |
Josh Johnson |
johnsoncustompaint@hotmail.com |
Fort Dodge |
Iowa |
United States |
JACKLYN JOHNSON |
Roger Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua Johnson |
johnsoncustompaint@hotmail.com |
owner |
Fort Dodge |
IA |
United States |
JACKLYN JOHNSON |
Roger Johnson |
Signed |
438 |
2021-03-17 06:52 |
Anonymous (not verified) |
198.167.182.164 |
David L Ridnour |
Proprietorship |
1415 4th St, Perry, IA 50220 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-16 |
David L Ridnour |
dlridnour@gmail.com |
Perry |
Dallas |
Iowa |
Steve Fishman |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David L Ridnour |
dlridnour@gmail.com |
Owner |
Perry |
Dallas |
Iowa |
Steve Fishman |
Dyan Kriener |
Signed |
1341 |
2022-10-23 14:31 |
Anonymous (not verified) |
97.127.255.147 |
Traver Home Improvement |
Limited Liability Company |
14150 110 th Ave. Davenport, IA 52804 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-24 |
Barry S Traver |
traverhomeimprovement@gmail.com |
Davenport |
IA |
United States |
Denise Baughman |
Joni Bryant |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Barry S Traver |
traverhomeimprovement@gmail.com |
self |
Davenport |
IA |
United States |
Denise Baughman |
Joni Bryant |
Signed |
1372 |
2022-11-14 20:36 |
Anonymous (not verified) |
198.14.213.147 |
Accurate Grading, LLC |
Limited Liability Company |
1417 290th St Macksburg, IA 50155 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-14 |
Dustin A McVay |
dustin0980@gmail.com |
Macksburg |
IA |
United States |
Dustin A McVay |
Angela D McVay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin A McVay |
dustin0980@gmail.com |
Owner |
Macksburg |
United States |
Iowa |
Dustin A McVay |
Angela D McVay |
Signed |
1626 |
2023-05-05 11:16 |
Anonymous (not verified) |
94.188.205.166 |
I HAWK BUILDERS LLC |
Limited Liability Company |
1417 INDIAN HILLS DR 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. |
2023-05-05 |
BEN BRANT |
babrant99@yahoo.com |
SPIRIT LAKE |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
BEN BRANT |
joel@walkerinsuranceia.com |
SELF |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1663 |
2023-05-25 12:56 |
Anonymous (not verified) |
94.188.205.167 |
Affordable Painting and Renovations of Iowa LLC |
Limited Liability Company |
1417 NW Applewood St. Ankeny, IA 50023 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-25 |
Bryan Thieleke |
affordablerenoiowa@yahoo.com |
Ankeny |
Polk |
Iowa |
Mike kaut |
Adam lozano |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bryan Thieleke |
affordablerenoiowa@yahoo.com |
Owner |
Ankeny |
Polk |
Iowa |
Mike kaut |
Adam lozano |
Signed |
1662 |
2023-05-25 12:52 |
Anonymous (not verified) |
94.188.205.176 |
Affordable Painting and Renovations of Iowa LLC |
Limited Liability Company |
1418 NW Applewood St. Ankeny, IA 50023 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-25 |
Bryan Thieleke |
affordablerenoiowa@yahoo.com |
Ankeny |
Polk |
Iowa |
Mike Kaut |
Adam Lozano |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bryan Thieleke |
affordablerenoiowa@yahoo.com |
Owner |
Ankeny |
Polk |
Iowa |
Mike kaut |
Adam lozano |
Signed |
1536 |
2023-03-27 10:47 |
Anonymous (not verified) |
94.188.205.174 |
Cecile C Knipp |
Limited Liability Company |
1418 Oakcrest 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. |
2023-03-27 |
Cecile C Knipp |
ceilknipp@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Monica Robbins |
Anne Betts |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cecile C Knipp |
christinaknipp@aol.com |
Self |
Waterloo |
Black Hawk |
Iowa |
Monica Robbins |
Anne Betts |
Signed |
1844 |
2023-09-14 14:15 |
Anonymous (not verified) |
94.188.205.177 |
Royal Gutters & Construction, LLC |
Limited Liability Company |
1420 120th Street, Hazleton, IA 50641 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-01 |
Andy Hershberger |
hershbergera@gmail.com |
Hazleton |
Buchanan |
Iowa |
Eli Raber |
Steve Frost |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andy Herschberger |
hershbergera@gmail.com |
self |
Hazleton |
Buchanan |
Iowa |
Eli Miller |
Steve Frost |
Signed |
1973 |
2024-01-02 17:05 |
Anonymous (not verified) |
94.188.207.227 |
Diego Puente |
Proprietorship |
1420 north st, apt#3 Perry 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. |
2024-01-02 |
Diego Puente Martinez |
diegopuente0655@gmail.com |
Perry |
Dallas |
Iowa |
Jason Van Dyke |
Ashley Heffernen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jason Van Dyke |
jvandyke@thermalshop.com |
worker |
Cedar Rapids |
Iowa |
United States |
Jason Van Dyke |
Ashley Heffernen |
Signed |
1871 |
2023-10-18 10:27 |
Anonymous (not verified) |
94.188.205.169 |
Derik Gonyier |
Proprietorship |
1421 Chicago Ave, Savanna, IL 61074 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-14 |
Derik Ray Gonyier |
deriknalexis121413@gmail.com |
Savanna |
Carroll |
IL |
Kyle Lee Sturtz |
Daryl Gonyier |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derik Ray Gonyier |
deriknalexis121413@gmail.com |
Self |
Savanna |
Carroll |
IL |
Kylee Lee |
Daryl Eugene Gonyier |
Signed |
1872 |
2023-10-18 10:59 |
Anonymous (not verified) |
94.188.205.177 |
Derik Gonyier |
Proprietorship |
1421 Chicago Ave, Savanna, IL 61074 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-14 |
Derik Ray Gonyier |
deriknalexis121413@gmail.com |
Savanna |
Carroll |
IL |
Kyle Lee Sturtz |
Daryl Eugene Gonyier |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derik Ray Gonyier |
deriknalexis121413@gmail.com |
Self |
Savanna |
Carroll |
IL |
Kyle Lee Sturtz |
Daryl Eugene Gonyier |
Signed |
1907 |
2023-11-15 09:45 |
Anonymous (not verified) |
94.188.205.168 |
Dan Taylor |
Proprietorship |
1422 State 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. |
2023-11-15 |
Daniel Taylor |
mailrunner1958@gmail.com |
Mason City |
Cerro Gordo |
IA |
Bob Smith |
Dave Clark |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Taylor |
mailrunner1958@gmail.com |
employee |
Mason City |
Cerro Gordo |
IA |
Bob Smith |
Dave Clark |
Signed |
264 |
2020-09-21 13:26 |
Anonymous (not verified) |
107.77.173.3 |
JAG Painting |
Proprietorship |
1423 Des Moines Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-21 |
Berenice S Silva |
berenicesssvaldes@gmail.com |
Des Moines |
Polk |
Iowa |
Luis Garcia |
Maria Salas |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Berenice S Silva |
berenicesssvaldes@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Luis Garcia |
Maria Salas |
Signed |
349 |
2020-12-31 17:37 |
Anonymous (not verified) |
107.77.161.33 |
JAG Painting |
Proprietorship |
1423 des moines street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-31 |
Berenice Silva |
berenicesssvaldes@gmail.com |
Des moines |
Polk |
IA |
Manuel Aguilar |
Luis Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Berenice Silva |
berenicesssvaldes@gmail.com |
Owner |
Des moines |
Polk |
Iowa |
Manuel Aguilar |
Luis Garcia |
Signed |
425 |
2021-03-05 16:03 |
Anonymous (not verified) |
65.103.82.36 |
Ryan Richard |
Proprietorship |
1425 W 34th Street, Davenport IA 52806 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Ryan Richard |
RRichard@gmail.com |
Davenport |
Scott |
Iowa |
Dawn Tague |
Eric Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Richard |
RRichard@gmail.com |
Self |
Davenport |
Scott |
Iowa |
Dawn Tague |
Eric Johnson |
Signed |
21 |
2020-01-01 18:16 |
Anonymous (not verified) |
72.35.186.80 |
Jerry Arnold |
Proprietorship |
1426 25th St, Humeston, IA 50123 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-01 |
Jerry Arnold |
LLArnold62@gmail.com |
Humeston |
Wayne |
Iowa |
Fred Throckmorton |
Joyce Throckmorton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jerry Arnold |
LLArnold62@gmail.com |
Self |
Humeston |
Wayne |
Iowa |
Fred Throckmorton |
Joyce Throckmorton |
Signed |
908 |
2022-02-09 15:06 |
Anonymous (not verified) |
63.152.66.183 |
Shear Texture |
Limited Liability Company |
1427 A Ave NW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-09 |
Wendy Kiser |
kiser187@msn.com |
Cedar Rapids |
Linn |
Iowa |
Shelly Wehr |
Kimberly Erickson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wendy Kiser |
kiser187@msn.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Shelly Wehr |
Kimberly Erickson |
Signed |
1586 |
2023-04-19 08:38 |
Anonymous (not verified) |
94.188.205.169 |
Arcos Siding, LLC |
Limited Liability Company |
1429 22nd Street, Des Moines, IA 50311 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-19 |
Alfredo Arco Cruz |
alfredoarcos13@gmail.com |
Des Moines |
Polk |
Des Moines |
Maria Sevillana Cruz |
Miguel Sevillana |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alfredo Arcos Cruz |
alfredoarco13@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Maria Sevillana Cruz |
Miguel Sevillana |
Signed |
245 |
2020-08-25 15:20 |
Anonymous (not verified) |
107.77.207.111 |
J&R cleaning co LLC |
Limited Liability Company |
14300 Holcomb ave #210 urbandale ia. 50323 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-25 |
José A salas romero |
chinito80sr@hotmail.com |
Desmoines |
Polk |
Iowa |
Ana López |
Jesus gonzales |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
José romero |
chinito80sr@hotmail.com |
Owner |
Desmoines |
Polk |
Iowa |
Ana lopez |
Jesus Gonzales |
Signed |
1576 |
2023-04-17 08:32 |
Anonymous (not verified) |
94.188.205.167 |
Reece Wilson |
Limited Liability Company |
1431 Starbeck Circle |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-14 |
Reece J Wilson |
rjwilson030@gmail.com |
Cedar Falls |
Blackhawk |
Iowa |
Kendall Cotant |
Darryl Mason |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Richter |
jrichter@beecherlaw.com |
Business |
Waterloo |
Blackhawk |
Iowa |
Kendall Cotant |
Jared Hottle |
Signed |
940 |
2022-03-01 11:08 |
Anonymous (not verified) |
216.51.251.31 |
trent montgomery trucking llc |
Limited Liability Company |
1432 eagle ridge circle pierce ne 68767 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-01 |
trent montgomery |
trent.montgomery7@gmail.com |
pierce |
pierce |
nebraska |
warren montgomery |
travis montgomery |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
trent montgomery |
trent.montgomery7@gmail.com |
self |
pierce |
pierce |
nebraska |
warren douglas montgomery |
travis warren montgomery |
Signed |
182 |
2020-06-11 14:18 |
Anonymous (not verified) |
173.29.64.73 |
Diamond Builders of Davenport INC |
Proprietorship |
14358 275th St, Long grove, IA 52756 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-11 |
Paula Woods |
paulawoods@diamond-builders.com |
Long Grove |
IA |
United States |
Colin Woods |
Joe Roozeboom |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tyler Green |
tyler@porterinsuranceinc.com |
Insurance Agent |
Long Grove |
IA |
United States |
Colin Woods |
Joe Roozeboom |
Signed |
459 |
2021-04-05 14:24 |
Anonymous (not verified) |
66.188.136.150 |
Gerald Bosch |
Proprietorship |
14359 County Rd. G62 Wapello, IA 52653 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-02 |
Gerald Bosch |
kschumacher@tricorinsurance.com |
Wapello |
Louisa |
IA |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gerald Bosch |
kschumacher@tricorinsurance.com |
Same |
Wapello |
Louisa |
IA |
Russell Masartis |
Shuree Behr |
Signed |
1753 |
2023-07-18 14:41 |
Anonymous (not verified) |
94.188.205.168 |
Cruz Lerma |
Proprietorship |
1439 17th Ct 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. |
2023-07-18 |
Cruz Lerma |
deb@picowa.com |
Des Moines |
Polk |
Iowa |
Deb Stratton |
Kelly K Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cruz Lerma |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Deb Stratton |
Kelly K Denger |
Signed |
889 |
2022-02-03 14:52 |
Anonymous (not verified) |
207.177.96.173 |
Stecker Rentals Inc. |
Limited Liability Company |
1439 Kate Shelley Dr. 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. |
2022-02-03 |
Holly Stecker |
hollystecker6@gmail.com |
Boone |
Boone |
IA |
Shana Mallas |
Laura Hutchcroft |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Holly Stecker |
hollystecker6@gmail.com |
Owner |
Boone |
Boone |
IA |
Shana Mallas |
Laura Hutchcroft |
Signed |
858 |
2022-01-27 08:06 |
Anonymous (not verified) |
75.162.81.119 |
MR Custom Tile & Flooring LLC |
Limited Liability Company |
14390 Newbold Street, Indianola, IA, 50125 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-27 |
Matthew Royer |
royer20@yahoo.com |
Indianola |
Warren |
United States |
Leiloni Royer |
Elena Royer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Royer |
royer20@yahoo.com |
Myself |
Indianola |
Warren |
United States |
Leiloni Royer |
Elena Royer |
Signed |
1510 |
2023-03-09 10:57 |
Anonymous (not verified) |
94.188.207.226 |
Sawyer Eblen |
Proprietorship |
14411 293rd Ave NE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-09 |
Sawyer Eblen |
sawyer.eblen@gmail.com |
Belgrade |
MN |
United States |
Brandon Keller |
Mitchell Vetsch |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sawyer Eblen |
sawyer.eblen@gmail.com |
Owner |
Belgrade |
MN |
United States |
Brandon Keller |
Mitchell Vetsch |
Signed |
71 |
2020-02-21 05:24 |
Anonymous (not verified) |
70.100.107.197 |
CRS Inc. |
Proprietorship |
1442 3rd Ave SW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-20 |
Monica Christensen |
monicalchristensen@gmail.com |
Belmond |
Wright |
Iowa |
Jessica Tempus |
Dawn Butler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Monica Christensen |
monicalchristensen@gmail.com |
Consultant |
Belmond |
Iowa |
United States |
Dawn Butler |
Jessica Tempus |
Signed |