1615 |
2023-04-27 17:42 |
Anonymous (not verified) |
94.188.207.227 |
John Anthony Davis |
Proprietorship |
P.O. Box 2551 Mountain View, AR 72560 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-27 |
John Anthony Davis |
turbinespacemonkey@yahoo.com |
Mountain View |
Stone |
Arkansas |
Vicki Lynne Ivey |
Maggielyn Marie Paul |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Anthony Davis |
turbinespacemonkey@yahoo.com |
Proprietor |
Mountain View |
Stone |
Arkansas |
Vicki Lynne Ivey |
Maggielyn Marie Paul |
Signed |
1616 |
2023-04-27 17:46 |
Anonymous (not verified) |
94.188.207.230 |
Davis AG Service Texas LLC |
Limited Liability Company |
P.O. Box 1475 Fabens, Texas 79838 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-27 |
John Anthony Davis |
turbinespacemonkey@yahoo.com |
Mountain View |
Stone |
Arkansas |
Vicki Lynne Ivey |
Maggielyn Marie Paul |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Anthony Davis |
turbinespacemonkey@yahoo.com |
Owner |
Mountain View |
Stone |
Arkansas |
Vicki Lynne Ivey |
Maggielyn Marie Paul |
Signed |
637 |
2021-09-10 15:15 |
Anonymous (not verified) |
204.155.61.217 |
Duwa Waterproofing LLC |
Limited Liability Company |
1548 150th Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-10 |
Stacy Duwa |
duwawaterproofing@gmail.com |
Mt Pleasant |
Henry |
Iowa |
Jeffrey Spenner |
Shawn Powell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stacy Duwa |
duwawaterproofing@gmail.com |
owner |
Mt Pleasant |
Henry |
Iowa |
Jeffrey Spenner |
Shawn Powell |
Signed |
2185 |
2024-04-26 16:46 |
Anonymous (not verified) |
94.188.205.166 |
Jerilyn Horn Kitchen and Bath Design Co. |
Proprietorship |
413 Jefferson St., Burlington, IA 52601 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-26 |
Jerilyn Michelle Horn |
designsbyjerilyn@gmail.com |
Mt. Pleasant |
Henry |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jerilyn Michelle Horn |
designsbyjerilyn@gmail.com |
owner |
Mt. Pleasant |
Henry |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
1053 |
2022-04-14 21:08 |
Anonymous (not verified) |
50.83.192.136 |
John E Snyder JR |
Proprietorship |
1677 PACIFIC ST, MURRAY, IA 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. |
2022-04-14 |
John Snyder JR |
jrsweldingia@gmail.com |
MURRAY |
Clarke |
Iowa |
Shelly Goslar |
Dorene Short |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Snyder JR |
jrsweldingia@gmail.com |
Selg |
MURRAY |
Clarke |
Iowa |
Shelly Goslar |
Dorene Short |
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 |
257 |
2020-09-14 16:15 |
Anonymous (not verified) |
66.129.217.166 |
Lisseth Carolina Salas Melendez |
Proprietorship |
3107 M & W Crl Muscatine, 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. |
2020-01-01 |
Lisseth Carolina Salas Melendez |
chonrosales88@gmail.com |
Muscatine |
Louisa |
IA |
Rafael Crespo |
Anthony Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lisseth Carolina Salas Melendez |
chonrosales88@gmail.com |
Same |
Muscatine |
Louisa |
IA |
Rafael Crespo |
Anthony Johnson |
Signed |
346 |
2020-12-31 10:39 |
Anonymous (not verified) |
66.129.217.166 |
GIL Construction, LLC |
Limited Liability Company |
3107 M & W Crl, Muscatine, IA 52761 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-20 |
Lisseth Melendez Gil |
chonrosales88@gmail.com |
Muscatine |
Iowa |
United States |
Donis Medina |
Anthony Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lisseth Melendez Gil |
chonrosales88@gmail.com |
Owner |
Muscatine |
Iowa |
United States |
Donis Medina |
Anthony Johnson |
Signed |
1639 |
2023-05-11 07:39 |
Anonymous (not verified) |
94.188.205.175 |
JYC Drywall LLC |
Proprietorship |
1034 Grand Ave, Muscatine, IA 52761 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-11 |
Anastacio Zamarripa |
1zama0081@gmail.com |
Muscatine |
Louisa |
Iowa |
Arcel Servin |
Chris Hay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Anastacio Zamarripa |
1zama0081@gmail.com |
Self |
Muscatine |
Louisa |
Iowa |
Arcel Servin |
Chris Hay |
Signed |
2230 |
2024-05-16 16:15 |
Anonymous (not verified) |
94.188.205.175 |
Hagerty LLC |
Proprietorship |
2816 Highway 22 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-16 |
RYAN JOESPH HAGERTY |
hagertyllc@gmail.com |
Muscatine |
IA |
United States |
Mary Wetzel |
Misty Wetzel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RYAN JOESPH HAGERTY |
hagertyllc@gmail.com |
owner of llc |
Muscatine |
IA |
United States |
Mary Wetzel |
Misty Wetzel |
Signed |
1128 |
2022-05-26 11:11 |
Anonymous (not verified) |
174.213.144.187 |
Leaf Filter |
Limited Liability Company |
3060 se grimes blvd suite 100-300 Grimes iowa 50111 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-24 |
Jason charlet |
jasonstreeservice2014@gmail.com |
Minburn |
Dallas |
Iowa |
Kami lillibridge |
Dale charlet |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
N/a |
jasoncharlet703@gmail.com |
N/a |
N/a |
N/a |
N/a |
N/a |
N/a |
Signed |
1137 |
2022-06-01 09:05 |
Anonymous (not verified) |
63.170.122.111 |
sanchez framing construction llc |
Limited Liability Company |
113 e a st west liberty, ia 52776 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-01 |
Cindy Sanchez |
sanchezframingconst.llc@gmail.com |
west liberty |
muscatine |
iowa |
patricia verdines |
yajahira estrada |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
n/a |
sanchezframingconst.llc@gmail.com |
n/a |
n/a |
n/a |
n/a |
n/a |
n/a |
Signed |
1418 |
2023-01-11 10:44 |
Anonymous (not verified) |
173.23.144.232 |
precision edge llc |
Limited Liability Company |
101 belmont st milo iowa 50116 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-10 |
erik reha |
precisionedgecompanies@gmail.com |
milo |
warren |
iowa |
bruce wilson |
jordan rhode |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
n/a |
precisionedgecompanies@gmail.com |
n/a |
n/a |
n/a |
n/a |
bruce wilson |
jordan rhode |
Signed |
1569 |
2023-04-12 16:19 |
Anonymous (not verified) |
94.188.205.166 |
Leaf home solutions llc |
Limited Liability Partnership |
1595 Georgetown rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-11 |
Gustavo Lopez |
Glopez2616@gmail.com |
Des Moines |
IA |
IA |
Ricardo lopez |
Maria lopez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
N/a |
sewell@leafhome.com |
N/a |
Na |
Na |
Na |
Na |
Na |
Signed |
497 |
2021-04-27 09:25 |
Anonymous (not verified) |
204.153.176.147 |
SHANE HUCK |
Proprietorship |
1070 305TH STREET, NASHUA, IOWA 50658 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-27 |
SHANE HUCK |
WOODHUCK@GMAIL.COM |
NASHUA |
CHICKASAW |
IOWA |
KIM LOECKLE |
RACHEL SCHNEIDER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SHANE HUCK |
WOODHUCK@GMAIL.COM |
OWNER |
NASHUA |
CHICKASAW |
IOWA |
KIM LOECKLE |
RACHEL SCHNEIDER |
Signed |
1810 |
2023-08-21 10:18 |
Anonymous (not verified) |
94.188.207.224 |
Vicente McCain |
Proprietorship |
524 panama st Nashua |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2023-08-20 |
Jose V Mccain |
Vic_mccain@yahoo.com |
Nashua |
IA |
United States |
Rafael McCain |
Jessica McCain |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jose V Mccain |
Vic_mccain@yahoo.com |
Brother |
Nashua |
IA |
United States |
Rafael McCain |
Jessica McCain |
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 |
1096 |
2022-05-12 15:47 |
Anonymous (not verified) |
64.64.128.230 |
Tim Woslager |
Limited Liability Company |
612 West 8th St Neligh Ne 68756 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-12 |
Tim Woslager |
timwoslager@icloud.com |
Neligh |
Antelope |
NE |
Trent Montgomery |
Travis Montgomery |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tim Woslager |
timwoslager@icloud.com |
Owner |
Neligh |
Antelope |
NE |
Trent Montgomery |
Travis Montgomery |
Signed |
1097 |
2022-05-12 15:47 |
Anonymous (not verified) |
64.64.128.230 |
Tim Woslager |
Limited Liability Company |
612 West 8th St Neligh Ne 68756 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-12 |
Tim Woslager |
timwoslager@icloud.com |
Neligh |
Antelope |
NE |
Trent Montgomery |
Travis Montgomery |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tim Woslager |
timwoslager@icloud.com |
Owner |
Neligh |
Antelope |
NE |
Trent Montgomery |
Travis Montgomery |
Signed |
2202 |
2024-05-06 11:36 |
Anonymous (not verified) |
94.188.207.224 |
Neil Wedeking |
Proprietorship |
408 Maple St, Nemaha, IA 50567 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-06 |
Neil Douglas Wedeking |
nandjwedeking@frontiernet.net |
Nemaha |
Sac |
Iowa |
Joseph McCollum |
Heather Husman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Neil Wedeking |
nandjwedeking@frontiernet.net |
Self |
Nemaha |
Sac |
Iowa |
Joseph Paul McCollum |
Heather Lee Husman |
Signed |
2025 |
2024-02-06 20:49 |
Anonymous (not verified) |
94.188.207.223 |
Blue Dog Stump Grinding |
Limited Liability Company |
32199 Sumac Road Neola IA 51559 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-06 |
Zebulan |
bluedogstumpgrinding@gmail.com |
Neola |
Pottowattamie |
Iowa |
Kelsey Wahle |
Mike Stamp |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Zebulan Wahle |
bluedogstumpgrinding@gmail.com |
Owner |
Neola |
Pottowattomie |
Iowa |
Kelsey Wahle |
Mike Stamp |
Signed |
2041 |
2024-02-12 10:37 |
Anonymous (not verified) |
94.188.207.230 |
Blue Dog Stump Grinding LLC |
Limited Liability Company |
32199 Sumac Rd Neola, IA 51559 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-12 |
Zebulan Kent Wahle |
bluedogstumpgrinding@gmail.com |
Neola |
Pottawattamie |
Iowa |
Kelsey Wahle |
Michael Stamp |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Zebulan Kent Wahle |
bluedogstumpgrinding@gmail.com |
Self |
Neola |
Pottawattamie |
Iowa |
Kelsey Wahle |
Michael Stamp |
Signed |
1063 |
2022-04-21 08:23 |
Anonymous (not verified) |
207.155.112.81 |
Prudenterra, LLC |
Limited Liability Company |
65584 260th 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-04-21 |
Luke Robert Gran |
luke@prudenterra.com |
Nevada |
Story |
Iowa |
Michael Joseph Coverdale |
Judy Rae Coverdale |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Luke Robert Gran |
luke@prudenterra.com |
Self |
Nevada |
Story |
Iowa |
Michael Joseph Coverdale |
Judy Rae Coverdale |
Signed |
1338 |
2022-10-17 15:53 |
Anonymous (not verified) |
74.84.121.206 |
Mark Mitchell |
Proprietorship |
P O Box 38 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-15 |
Mark Mitchell |
darrele@ciains.biz |
New Albion |
Allamakee |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Mitchell |
darrele@ciains.biz |
Self |
New Albion |
Allamakee |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
83 |
2020-02-28 12:55 |
Anonymous (not verified) |
204.16.58.27 |
Baltes Trucking LLC |
Limited Liability Company |
203 N Gilmore Ave New Hampton IA 50659 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-28 |
Clinton Lee Baltes |
clintbaltes@gmail.com |
New Hampton |
Chickasaw |
Iowa |
Tammy Robinson |
Richard Kramer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Clinton Lee Baltes |
clintbaltes@outlook.com |
Owner |
New Hampton |
Chickasaw |
Iowa |
Tammy Robinson |
Richard Kramer |
Signed |
24 |
2020-01-03 12:41 |
Anonymous (not verified) |
63.152.13.239 |
Eden Plumbing LLC TJ Eden |
Limited Liability Company |
502 Packwaukee Street New Hartford, IA 50660 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-03 |
TJ Eden |
edentj@aol.com |
New Hartford |
IA |
United States |
Ann Robinson |
Nate Schmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
PDCM Insurance- Nate Schmidt |
NSCHMIDT@PDCM.COM |
Member |
New Hartford |
Butler |
Iowa |
Ann Robinson |
Nate Schmidt |
Signed |
2208 |
2024-05-07 12:44 |
Anonymous (not verified) |
94.188.205.169 |
Tom Franklin |
Proprietorship |
2353 Salem Road, New London, IA 52645 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-07 |
Thomas Eric Franklin |
68carpetman@gmail.com |
New London |
Henry |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Thomas Eric Franklin |
68carpetman@gmail.com |
owner |
New London |
Henry |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
608 |
2021-08-17 21:35 |
Anonymous (not verified) |
50.82.65.174 |
33z Racing, LLC |
Limited Liability Company |
307 N Park Ave, New Sharon, IA. 50207 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-17 |
James D VanderBeek |
jvanderbeek@plbci.com |
New Sharon |
Mahaska |
IA |
Barbara M VanderBeek |
Zackery James VanderBeek |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Barbara M VanderBeek |
bvanderbeek33z@gmail.com |
Spouse |
New Sharon |
Mahaska |
IA |
James D VanderBeek |
Zackery J VanderBeek |
Signed |
609 |
2021-08-17 21:42 |
Anonymous (not verified) |
50.82.65.174 |
33z Racing, LLC |
Limited Liability Company |
307 N Park Ave, New Sharon, IA. 50207 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-17 |
Zackery James VanderBeek |
zackvanderbeek@gmail.com |
New Sharon |
Mahaska |
IA |
Barbara M VanderBeek |
James. VanderBeek |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Barbara M VanderBeek |
bvanderbeek33z@gmail.com |
Mother |
New Sharon |
Mahaska |
IA |
James D VanderBeek |
Barbara M VanderBeek |
Signed |
612 |
2021-08-19 21:50 |
Anonymous (not verified) |
50.82.65.174 |
33z Racing,, LLC |
Limited Liability Company |
307 N Park Ave, New Sharon, Iowa 50207 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-20 |
James Dean VanderBeek |
jvanderbeek@plbco.com |
New Sharon |
Mahaska |
Iowa |
Margaret Ratcliff |
Billy Blake |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Barbara M VanderBeek |
bvanderbeek33z@gmail.com |
Spouse |
New Sharon |
Mahaska |
Iowa |
Margaret Ratcliff |
Billy Blake |
Signed |
613 |
2021-08-19 21:54 |
Anonymous (not verified) |
50.82.65.174 |
33z Racing, LLC |
Limited Liability Company |
307 N Park Ave, New Sharon, Iowa 50207 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-20 |
Zackery J VanderBeek |
zackvanderbeek@gmail.com |
New Sharon |
Mahaska |
IA |
Margaret Ratcliff |
Billy Blake |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Barbara M VanderBeek |
bvanderbeek33z@gmail.com |
Mother |
New Sharon |
Mahaska |
IA |
Margaret Ratcliff |
Billy Blake |
Signed |
1302 |
2022-09-11 22:05 |
Anonymous (not verified) |
174.198.65.241 |
Bruce g Sellner |
Proprietorship |
40998 597th ave new ulm mn 56073 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-11 |
Bruce g Sellner |
bgsellner74@gmail.com |
New ulm |
Nicollet |
Minnesota |
Carol m aura |
Steve l griebel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bruce g Sellner |
bgsellner74@gmail.com |
Owner |
New ulm |
Nicollet |
Mn |
Carol m aura |
Steve l griebel |
Signed |
1303 |
2022-09-11 22:05 |
Anonymous (not verified) |
174.198.65.241 |
Bruce g Sellner |
Proprietorship |
40998 597th ave new ulm mn 56073 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-11 |
Bruce g Sellner |
bgsellner74@gmail.com |
New ulm |
Nicollet |
Minnesota |
Carol m aura |
Steve l griebel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bruce g Sellner |
bgsellner74@gmail.com |
Owner |
New ulm |
Nicollet |
Mn |
Carol m aura |
Steve l griebel |
Signed |
1304 |
2022-09-11 22:05 |
Anonymous (not verified) |
174.198.65.241 |
Bruce g Sellner |
Proprietorship |
40998 597th ave new ulm mn 56073 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-11 |
Bruce g Sellner |
bgsellner74@gmail.com |
New ulm |
Nicollet |
Minnesota |
Carol m aura |
Steve l griebel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bruce g Sellner |
bgsellner74@gmail.com |
Owner |
New ulm |
Nicollet |
Mn |
Carol m aura |
Steve l griebel |
Signed |
104 |
2020-03-26 19:00 |
Anonymous (not verified) |
173.189.167.170 |
MCB CONSTRUCTION INC |
Limited Liability Company |
3484 VERMONT 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. |
2020-03-26 |
michael wade bethards |
mwbethards@yahoo.com |
NEW VIRGINIA |
IA |
IA |
noel isaac |
alice lohmann |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
mike bethards |
mwbethards@yahoo.com |
owner |
New Virginia |
warren |
IA |
noel isaac |
alice lohmann |
Signed |
801 |
2021-12-16 21:35 |
Anonymous (not verified) |
98.21.205.195 |
Kustom Home Improvements |
Proprietorship |
400 Davidson st new Virginia Iowa 50210 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-16 |
David Jack Kimmel |
kustomhomeimprovements.dk@gmail.com |
New Virginia |
Warren |
Iowa |
Cindy Sue Gyles |
Shantell Christine Rice |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Jack Kimmel |
kustomhomeimprovements.dk@gmail.com |
Self |
New Virginia |
Warren |
Iowa |
Cindy Sue Gyles |
Shantell Christine Rice |
Signed |
802 |
2021-12-16 21:44 |
Anonymous (not verified) |
98.21.205.195 |
Kustom Home Improvements |
Proprietorship |
400 Davidson St New Virginia Iowa 50210 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-16 |
Jeffrey Allen Webster |
kustomhomeimprovements.dk@gmail.com |
New Virginia |
Warren |
Iowa |
Cindy Sue Gyles |
Shantell Christine Rice |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Jack Kimmel |
kustomhomeimprovements.dk@gmail.com |
Self |
New Virginia |
Warren |
Iowa |
Cindy Sue Gyles |
Shantell Christine Rice |
Signed |
803 |
2021-12-16 21:47 |
Anonymous (not verified) |
98.21.205.195 |
Kustom Home Improvements |
Proprietorship |
400 Davidson St New Virginia Iowa 50210 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-16 |
Ethan Willett |
kustomhomeimprovements.dk@gmail.com |
Osceola |
Clarke |
Iowa |
Cindy Sue Gyles |
Shantell Christine Rice |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Jack Kimmel |
kustomhomeimprovements.dk@gmail.com |
Self |
New Virginia |
Warren |
Iowa |
Cindy Sue Gyles |
Shantell Christine Rice |
Signed |
804 |
2021-12-16 21:51 |
Anonymous (not verified) |
98.21.205.195 |
Kustom Home Improvements |
Proprietorship |
400 Davidson st New Virginia Iowa 50210 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-16 |
Curtis Allen Masterson |
kustomhomeimprovements.dk@gmail.com |
New Virginia |
Warren |
Iowa |
Cindy Sue Gyles |
Shantell Christine Rice |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Jack Kimmel |
kustomhomeimprovements.dk@gmail.com |
Self |
New Virginia |
Warren |
Iowa |
Cindy Sue Gyles |
Shantell Christine Rice |
Signed |
897 |
2022-02-04 15:15 |
Anonymous (not verified) |
163.116.133.119 |
Schauf Investments LLC |
Limited Liability Company |
3465 Vermont Street, New Virginia, 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. |
2022-02-04 |
Maxwell Schauf |
max.schauf@gmail.com |
New Virginia |
IA |
United States |
Krisha Schauf |
Robin Schauf |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maxwell Schauf |
max.schauf@gmail.com |
General Member |
New Virginia |
IA |
United States |
Krisha Schauf |
Robin Schauf |
Signed |
1812 |
2023-08-22 08:00 |
Anonymous (not verified) |
94.188.207.230 |
mike bethards |
Proprietorship |
3484 vermont st new virginia ia 50210 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-22 |
mike w bethards |
mwbethards@yahoo.com |
new virginia |
ia |
United States |
christine bethards |
alice lohan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
mike bethards |
mwbethards@yahoo.com |
same |
new virginia |
ia |
United States |
christine bethards |
alice lohan |
Signed |
1864 |
2023-10-09 09:52 |
Anonymous (not verified) |
94.188.207.223 |
Admiral Staffing Inc |
Limited Liability Company |
580 8th Ave, 15th Floor, New York NY 10018 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-09 |
Rezwan Rafeek |
ray@admiralstaffinginc.com |
23 Catalpa Lane |
Valley Stream |
NY |
Ikbal Sherif |
Salim Balee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shafi Rafeek |
shafi@admiralstaffinginc.com |
Office Manager |
New York |
NY |
United States |
Ikbal Sherif |
Salin Balee |
Signed |
1020 |
2022-03-29 16:53 |
Anonymous (not verified) |
207.32.60.144 |
J.A. Dahlhauser, Ltd. |
Proprietorship |
1741 Hwy. 7 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-29 |
Jaylin A. Dahlhauser |
jaydahlhauser@gmail.com |
Newell |
IA |
United States |
Matthew McClellan |
Gracelin R. Dahlhauser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jaylin A. DAhlhauser |
jaydahlhauser@gmail.com |
Owner |
Newell |
IA |
United States |
Matthew McClellan |
Gracelin R. Dahlhauser |
Signed |
1760 |
2023-07-26 08:16 |
Anonymous (not verified) |
94.188.207.230 |
MCH Pig LLC |
Limited Liability Company |
5434 180th Ave Albert City, IA 50510 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-26 |
Mitchell Hogrefe |
mhogrefe@nfpinc.com |
Newell |
Buena Vista |
Iowa |
Kyle Klein |
Brenda Klein |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mitchell Hogrefe |
mhogrefe@nfpinc.com |
Owner |
Newell |
Buena Vista |
Iowa |
Kyle Klein |
Brenda Klein |
Signed |
943 |
2022-03-03 13:49 |
Anonymous (not verified) |
192.95.125.191 |
B & R Enterprises LLC |
Limited Liability Company |
2850 73rd St, Newhall, IA 52315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2022-02-17 |
Ronald Jarrett |
ashlyn@3riversins.net |
Newhall |
Benton |
Iowa |
Ashlyn Christianson |
Angie McFarland |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Ronald Jarrett |
brsirenguys@gmail.com |
Member of LLC |
Newhall |
Benton |
Iowa |
Ashlyn Christianson |
Angie McFarland |
Signed |
944 |
2022-03-03 13:54 |
Anonymous (not verified) |
192.95.125.191 |
B&R Enterprises LLC |
Limited Liability Company |
2850 73rd St., Newhall, IA 52315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2022-02-17 |
Bradley Rick |
ashlyn@3riversins.net |
Newhall |
Benton |
Iowa |
Ashlyn Christianson |
Angie McFarland |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Ronald Jarrett |
brsirenguys@gmail.com |
LLC Member |
Newhall |
Benton |
Iowa |
Ashlyn Christianson |
Angie McFarland |
Signed |
1746 |
2023-07-14 09:21 |
Anonymous (not verified) |
94.188.205.176 |
Alex Webb |
Proprietorship |
4019 West Roderweis Road Cabot Ar 72023 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-14 |
Alex Webb |
frankie.webb@yahoo.com |
Cabot |
Pulaski |
Arkansas |
Mark Ellis |
Becky Ellis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ellis Flying Service INC. |
fly@ellisflying.com |
President |
Newport |
Arkansas |
United States |
Alex Webb |
Becky Ellis |
Signed |
626 |
2021-08-31 11:39 |
Anonymous (not verified) |
166.181.81.253 |
Birds landscape maintenance LLC |
Limited Liability Company |
1307 w 4th st south |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-31 |
Michael Alan bird |
birdslawn@hotmail.com |
Newton |
Jasper |
Iowa |
Jeff Dennis carder |
Dustin James bos |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Alan bird |
birdslawn@hotmail.com |
Same - owner |
Newton |
Jasper |
Iowa |
Jeff Dennis carder |
Dustin James bos |
Signed |
756 |
2021-11-19 14:05 |
Anonymous (not verified) |
65.144.174.26 |
Jaime Hernandez Lopez |
Proprietorship |
223 N 9th Ave W, Newton, Iowa 50208 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-19 |
Jaime Hernandez Lopez |
jaimehernandezlopez81@yahoo.com |
Newton |
Jasper |
Iowa |
Megan Ackerly |
Antonio Lopez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jaime Hernandez Lopez |
jaimehernandezlopez81@yahoo.com |
Self |
Newton |
Jasper |
Iowa |
Megan Ackerly |
Antonio Lopez |
Signed |
844 |
2022-01-20 08:55 |
Anonymous (not verified) |
172.58.87.106 |
Barkley Coatings |
Limited Liability Company |
305 E 20th St 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. |
2022-01-20 |
Heath |
barkleyheath@yahoo.com |
Newton |
United States |
Iowa |
Matthew Blunk |
Hailey Scott |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Heath Barkley |
barkleyheath@yahoo.com |
Owner |
Newton |
IA |
United States |
Matthew Blunk |
Hailey Scott |
Signed |
1164 |
2022-06-23 09:26 |
Anonymous (not verified) |
74.84.106.106 |
Kimberly Owens |
Proprietorship |
2503 E 23rd street Newton, IA 50228 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-23 |
Kimberly Owens |
kimmybobby1220@gmail.com |
Newton |
Jasper |
Iowa |
Rita Littrell |
Tina Owens |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kimberly Owens |
kimmybobby1220@gmail.com |
Self |
Newton |
Jasper |
Iowa |
Rita Littrell |
Tina Owens |
Signed |
1207 |
2022-07-15 10:02 |
Anonymous (not verified) |
75.89.78.50 |
A&J Remodeling LLC |
Limited Liability Company |
2 Bungalow Ct Newton, Iowa 50208 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-15 |
Austin Hudson |
ahudson7536@gmail.com |
Newton |
Jasper |
IA |
Liz Allen |
Dustin Ingram |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Austin Hudson |
anjremodel@gmail.com |
Co-owner |
Newton |
Jasper |
IA |
Liz Allen |
Dustin Ingram |
Signed |
1210 |
2022-07-18 08:15 |
Anonymous (not verified) |
173.22.187.234 |
Cardinal Rule Handyman Services, LLC |
Limited Liability Company |
1304 E 10th St S, Newton, IA 50208 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-18 |
James Andrew Dunlap |
cardinarulehandyman@gmail.com |
Newton |
Jasper |
Iowa |
Jacinda Marie Dunlap |
James Thornton Dunlap |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Andrew Dunlap |
cardinalrulehandyman@gmail.com |
I am the authorized agent |
Newton |
Jasper |
Iowa |
Jacinda Marie Dunlap |
James Thornton Dunlap |
Signed |
1373 |
2022-11-16 12:28 |
Anonymous (not verified) |
173.22.187.22 |
MCDONALD'S LAWN & TREE SERVICES |
Proprietorship |
1130 N. 4 AVE. W. NEWTON IA 50208 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-16 |
Roger McDonald |
RABBITMCDONALD@HOTMAIL.COM |
Newton |
IA |
United States |
Patricia McMahon |
Bryan McMahon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Roger McDonald |
RABBITMCDONALD@HOTMAIL.COM |
Self |
Newton |
IA |
United States |
Patricia McMahon |
Bryan McMahon |
Signed |
1791 |
2023-08-08 15:22 |
Anonymous (not verified) |
94.188.207.227 |
dutch meadows lawn care |
Limited Liability Company |
304 W 9TH ST. 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. |
2023-08-08 |
david nunnikhoven |
djnunnik@iowatelecom.net |
newton |
Iowa |
United States |
david nunnikhoven |
david nunnikhoven |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
david nunnikhoven |
djnunnik@iowatelecom.net |
owner |
newton |
Iowa |
United States |
david nunnikhoven |
david nunnikhoven |
Signed |
1837 |
2023-09-11 19:10 |
Anonymous (not verified) |
94.188.207.230 |
TBA Handyman service |
Limited Liability Company |
619 e 10th st. north newton Iowa 50208 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-11 |
Joey Conkling |
tba050402@gmail.com |
newton |
jasper |
Iowa |
Ashton tyler conkling |
Bianca Storm Conkling |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
TBA Handyman Service |
tbaconstruction02@gmail.com |
self |
newton |
jasper |
iowa |
Ashton tyler Conkling |
Bianca Storm Conkling |
Signed |
286 |
2020-10-21 18:32 |
Anonymous (not verified) |
173.218.73.44 |
Bilyeu Underground LLC |
Limited Liability Company |
1136 W. Irene Ct. Nixa, MO 65714 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-21 |
Daniel Bilyeu |
danielbilyeu@gmail.com |
Nixa |
Christian |
Missouri |
Gary George Bilyeu |
Chad Anthony Charles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Bilyeu |
danielbilyeu@gmail.com |
Owner |
Nixa |
Christian |
Missouri |
Gary George Bilyeu |
Chad Anthony Charles |
Signed |
288 |
2020-10-21 18:36 |
Anonymous (not verified) |
173.218.73.44 |
Bilyeu Underground LLC |
Limited Liability Company |
1136 W. Irene Ct. Nixa, MO 65714 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-21 |
Chad Anthony Charles |
y4ardgn0m3r@gmail.com |
Nixa |
Christian |
Missouri |
Gary George Bilyeu |
Daniel Bilyeu |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chad Anthony Charles |
y4ardgn0m3r@gmail.com |
Owner |
Nixa |
Christian |
Missouri |
Gary George Bilyeu |
Daniel Bilyeu |
Signed |
1350 |
2022-10-31 10:42 |
Anonymous (not verified) |
108.160.48.9 |
gaes trucking |
Proprietorship |
84642 Dun Rd Norfolk, NE 68701 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-31 |
SHANE GAES |
scgaes@icloud.com |
Norfolk |
NE |
United States |
Bill Rich |
Ben Becker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
shane gaes |
scgaes@icloud.com |
self |
norfolk |
pierce county nebraska |
nebraska |
Bill Rich |
Ben Becker |
Signed |
102 |
2020-03-25 11:23 |
Anonymous (not verified) |
206.72.14.249 |
Brandi Wehr |
Proprietorship |
123 E Marion St, Sigourney, IA 52591 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-25 |
Brandi Jo Wehr |
brndwehr54@hotmail.com |
Sigourney |
Keokuk |
Iowa |
Amber Kephart |
Mary Beth Knipfer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chelsea Voss |
chelsea@grimmrealestate.com |
Agent |
North English |
Iowa |
Iowa |
Amber Kephart |
Mary Beth Knipfer |
Signed |
384 |
2021-02-03 20:36 |
Anonymous (not verified) |
66.129.217.166 |
GIL Construction, LLC |
Limited Liability Company |
3107 M & W Crl |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Lisseth Melendez Gil |
tonypauljohnson@yahoo.com |
Muscatine |
Iowa |
United States |
Rafael Medina |
Anthony Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lisseth Melendez Gil |
tonypauljohnson@yahoo.com |
Owner |
North Liberty |
IA |
United States |
Rafael Medina |
Anthony Johnson |
Signed |
1010 |
2022-03-28 09:20 |
Anonymous (not verified) |
173.21.74.26 |
Self-employed (Stacy Davids) |
Proprietorship |
35 Lynx Lane, 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. |
2022-03-28 |
Stacy Ann Davids |
stacyanndavids@gmail.com |
North Libery |
Johsnons |
IOWA |
Darin Gylten |
Zara Wanlass |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stacy Ann Davids |
stacyanndavids@gmail.com |
self |
North Liberty |
Johnson |
Iowa |
Darin Gylten |
Zara Wanlass |
Signed |
1043 |
2022-04-12 18:20 |
Anonymous (not verified) |
66.129.218.53 |
DON'S LOCK & SAFE LLC |
Proprietorship |
4223 YVETTE ST SUITE 101, IOWA CITY, IA 52240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-12 |
BRIAN E LOUGH |
LOLOCK@LIVE.COM |
NORTH LIBERTY |
JOHNSON |
IOWA |
WILLIAM H CRILE |
KELLI L SCOTT |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
BRIAN E LOUGH |
LOLOCK@LIVE.COM |
OWNER |
NORTH LIBERTY |
JOHNSON |
IA |
WILLIAM H CRILE |
KELLI L SCOTT |
Signed |
1074 |
2022-04-27 12:16 |
Anonymous (not verified) |
66.129.216.227 |
Kristyn M Gerst Counseling LLC |
Limited Liability Company |
30 Villager Dr. Apt. 3 North Liberty, IA 52317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-27 |
Kristyn May Gerst |
kmwatson18@gmail.com |
North Liberty |
johnson |
Iowa |
Forrest John Gerst |
Heather Lynn Watson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kristyn May Gerst |
kmwatson18@gmail.com |
self |
North Liberty |
Johnson |
Iowa |
Forrest John Gerst |
Heather Lynn Watson |
Signed |
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 |
1331 |
2022-10-11 13:17 |
Anonymous (not verified) |
174.216.2.52 |
Parceros Construction LLC |
Limited Liability Company |
2315 Landon Rd. Apt. 206 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. |
2022-10-11 |
Laura Garavito |
ldanielagaravitog@gmail.com |
North Liberty |
Johnson |
IA |
Derek Davis |
Cory Beesler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Laura Garavito |
ldanielagaravitog@gmail.com |
Owner |
North Liberty |
Johnson |
IA |
Derek Davis |
Cory Beesler |
Signed |
1815 |
2023-08-23 14:16 |
Anonymous (not verified) |
94.188.207.228 |
JP Distribution, LLC |
Limited Liability Company |
3738 Pine Rdg 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. |
2023-08-23 |
Jared Prelle |
jpdist2014@gmail.com |
North Liberty |
IA |
United States |
Linda Stien |
Dawn Franck |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jared Prelle |
jpdist2014@gmail.com |
Owner |
North Liberty |
Johnson |
IA |
Linda Stien |
Dawn Franck |
Signed |
1866 |
2023-10-11 08:17 |
Anonymous (not verified) |
94.188.205.177 |
Wilson's Window Tinting |
Limited Liability Company |
385 South Stewart Street North Liberty, Iowa 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. |
2023-10-07 |
Wilson Paiva |
wilsonswindowtinting@gmail.com |
North Liberty |
IA |
United States |
John W. Helscher |
Jose Omar Paz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wilson Paiva |
wilsonswindowtinting@gmail.com |
Owner |
North Liberty |
IA |
United States |
John Helscher |
Jose Omar Paz |
Signed |
1990 |
2024-01-16 22:22 |
Anonymous (not verified) |
94.188.205.168 |
DeltaPro Painting & Remodeling |
Limited Liability Company |
1115 Nolan Court North Liberty 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. |
2024-01-16 |
Bayron Amador |
bayronamador59@gmail.com |
North Liberty |
IA |
Estados Unidos |
Claudia Garmendia |
Marlon Amador |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bayron Amador |
bayronamador59@gmail.com |
Owner/Employer |
North Liberty |
IA |
Estados Unidos |
Claudia Garmendia |
Marlon Amador |
Signed |
11 |
2019-12-17 19:46 |
Anonymous (not verified) |
50.83.188.192 |
B & B Construction |
Proprietorship |
2463 93rd Avenue, Norwalk, IA 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-17 |
Louis I. Maxwell |
brockbrooke2463@yahoo.com |
Norwalk |
IA |
United States |
Hope Winegardner |
Yvonne Ginther |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Louis Maxwell |
brockbrooke2463@yahoo.com |
Owner |
Norwalk |
IA |
United States |
Hope Winegardner |
Yvonne Ginther |
Signed |
258 |
2020-09-15 13:14 |
Anonymous (not verified) |
50.83.182.140 |
Moyer Painting |
Proprietorship |
934 Norwood Drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-15 |
jerome Moyer |
moyer_painting@live.com |
Norwalk |
IA |
United States |
Sally Moyer |
Adam Adams |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
jerome b moyer |
moyer_painting@live.com |
Self |
norwalk |
IA |
United States |
sally moyer |
Adam Adams |
Signed |
576 |
2021-07-14 18:13 |
Anonymous (not verified) |
69.169.10.40 |
J&M Excavation Inc. |
Limited Liability Company |
411 Pine Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-14 |
Bruce Bilyeu |
jmexcavation@outlook.com |
Norwalk |
Warren |
IA |
Mike Petersen |
Dennis Bilyeu |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bruce Bilyeu |
jmexcavation@outlook.com |
Owner |
Norwalk |
Warren |
IA |
Mike Petersen |
Dennis Bilyeu |
Signed |
635 |
2021-09-10 13:41 |
Anonymous (not verified) |
166.181.84.226 |
JZH Roofing Specialists LLC |
Limited Liability Company |
2127 Swan Dr, Norwalk, Iowa. 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-10 |
Jayme Alexander Christian Heiselman |
wrkhrd2plyhrd04@gmail.com |
Norwalk |
Warren |
Iowa |
Melanie Handy |
Jesse Hagge |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jayme Alexander Christian Heiselman |
wrkhrd2plyhrd04@gmail.com |
Single member |
Norwalk |
Warren |
Iowa |
Melanie Handy |
Jesse Hagge |
Signed |
682 |
2021-10-19 16:15 |
Anonymous (not verified) |
65.144.174.26 |
BBR Tile and Professional Installation LLC |
Proprietorship |
903 School Ave Norwalk, IA 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-19 |
Bertin Baltazar |
baltarey2009@gmail.com |
Norwalk |
Warren |
Iowa |
Enedelia Bonilla |
Fernando Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bertin Baltazar |
baltarey2009@gmail.com |
Owner |
Norwalk |
Warren |
Iowa |
Enedelia Bonilla |
Fernando Garcia |
Signed |
710 |
2021-11-04 12:57 |
Anonymous (not verified) |
50.83.182.182 |
United Trades Group LLC |
Limited Liability Company |
4813 Candlewick Drive Norwalk Iowa 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-04 |
Tory Webb |
torywebbdmi@gmail.com |
Norwalk |
Polk |
Iowa |
Ryan Drabek |
Dustin Kohler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tory Webb |
toryw@unitedtradesgroup.org |
Owner, Management |
Norwalk |
Iowa |
United States |
Ryan Drabek |
Dustin Kohler |
Signed |
732 |
2021-11-09 15:25 |
Anonymous (not verified) |
50.83.182.182 |
United Trades Group LLC |
Limited Liability Company |
4813 Candlewick Drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-09 |
Ryan Drabek |
ryand@unitedtradesgroup.org |
Des Moines |
Polk |
Iowa |
Dustin Kohler |
Trevor Spidle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tory Webb |
toryw@unitedtradesgroup.org |
Owner, Management |
Norwalk |
Warren |
Iowa |
Trevor Spidle |
Dustin Kohler |
Signed |
733 |
2021-11-09 15:35 |
Anonymous (not verified) |
50.83.182.182 |
United Trades Group LLC |
Limited Liability Company |
4813 Candlewick Drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-09 |
Dustin Kohler |
dustink@unitedtradesgroup.org |
Des Moines |
Polk |
Iowa |
Ryan Drabek |
Trevor Spidle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tory Webb |
torywebbdmi@gmail.com |
Owner, Management |
Norwalk |
Warren |
Iowa |
Ryan Drabek |
Trevor Spidle |
Signed |
916 |
2022-02-16 09:23 |
Anonymous (not verified) |
173.18.22.217 |
Cesar Ponce |
Proprietorship |
150 Aspen Dr. Norwalk IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-16 |
Cesar Ponce |
cesarponce00@icloud.com |
Nowalk |
Warren |
Iowa |
Lesa Reeves |
Jennifer Lambert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cesar Ponce |
cesarponce00@icloud.com |
Owner |
Norwalk |
Warren |
Iowa |
Lesa Reeves |
Jennifer Lambert |
Signed |
1025 |
2022-04-01 09:32 |
Anonymous (not verified) |
173.23.251.188 |
Dakota Lester |
Proprietorship |
2711 Cedar St Norwalk, IA 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-01 |
Dakota Lester |
dlester18@icloud.com |
Norwalk |
Warren |
Iowa |
Tara Murphy |
Mike Ryerson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dakota Lester |
dlester18@icloud.com |
owner |
Norwalk |
Warren |
Iowa |
Tara Murphy |
Mike Ryerson |
Signed |
1116 |
2022-05-17 21:41 |
Anonymous (not verified) |
75.162.182.172 |
Hinds Metal Designs LLC |
Limited Liability Company |
11409 Dakota St, Norwalk, IA 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-18 |
Brad Hinds |
bahinds@msn.com |
Norwalk |
Iowa |
Iowa |
Trevor Masten |
Travis Masten |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Carlene Hinds |
carlene4082@msn.com |
Self |
Norwalk |
Iowa |
Iowa |
Trevor Masten |
Travis Masten |
Signed |
1206 |
2022-07-14 14:34 |
Anonymous (not verified) |
75.162.163.45 |
General construction services |
Proprietorship |
7071 30th Ave norwalk IA 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-14 |
ned cunconan |
ned.gcs@gmail.com |
Norwalk |
polk |
IA |
Sheena Cunconan |
Sheena Cunconan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
ned cunconan |
ned.gcs@gmail.com |
subcontractor |
Norwalk |
polk |
Iowa |
Sheena Cunconan |
Sheena Cunconan |
Signed |
1381 |
2022-11-30 20:41 |
Anonymous (not verified) |
97.125.145.12 |
Central Iowa Outdoor Services |
Proprietorship |
1213 Parkhill Dr. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-30 |
Keegan Eggers |
CentralIowaServices1@gmail.com |
Norwalk |
Iowa |
United States |
Stephanie Eggers |
Kelsie Eggers |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Keegan Eggers |
CentralIowaServices1@gmail.com |
Owner |
Norwalk |
Iowa |
United States |
Stephanie Eggers |
Kelsie Eggers |
Signed |
1390 |
2022-12-12 10:27 |
Anonymous (not verified) |
97.125.170.79 |
Norwalk Cleaning Servicesw |
Limited Liability Company |
520 W High Rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-12-12 |
Jacob Hibbert |
Maryhib@icloud.com |
Norwalk |
IA |
United States |
Kyle Grandstaff |
Nicole Nichols |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jacob Hibbert |
maryhib@icloud.com |
Self |
Norwalk |
Warren |
United States |
Kyle Grandstaff |
Nicole Nichols |
Signed |
1468 |
2023-02-17 16:17 |
Anonymous (not verified) |
94.188.207.230 |
AJ Cook LLC |
Limited Liability Company |
1817 Redbud Street, Norwalk, IA 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-17 |
Alejandro Cook |
alejandro.cook14@gmail.com |
Norwalk |
Warren |
Iowa |
Steve Bieghler |
Nichole Bishop |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alejandro Cook |
alejandro.cook14@gmail.com |
Self |
Norwalk |
Warren |
Iowa |
Steve Bieghler |
Nichole Bishop |
Signed |
1515 |
2023-03-13 15:04 |
Anonymous (not verified) |
94.188.207.226 |
Flint Hillman |
Proprietorship |
1019 E 17th St, APT 16, Norwalk, IA 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-13 |
Flint Hillman |
flinthillman@gmail.com |
Norwalk |
Warren |
Iowa |
Tina Robinson |
Paige Robinson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Flint Hillman |
flinthillman@gmail.com |
Self |
Norwalk |
Warren |
Iowa |
Tina Robinson |
Paige Robinson |
Signed |
1732 |
2023-07-10 13:22 |
Anonymous (not verified) |
94.188.207.224 |
Jovan Guerrero |
Proprietorship |
2887 Jaden Lane Norwalk, Iowa 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-10 |
Jovan Guerrero |
deb@piciowa.com |
Norwalk |
Warren |
Iowa |
Debra Stratton |
Kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jovan Guerrero |
deb@piciowa.com |
self |
Norwalk |
Warren |
Iowa |
Debra Stratton |
Kelly Denger |
Signed |
1814 |
2023-08-23 13:57 |
Anonymous (not verified) |
94.188.207.229 |
Exclusive Solutions LLC dba Jovan Guerrero |
Limited Liability Company |
2887 Jaden Lane Norwalk, Iowa 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-10 |
Jovan guerrero dba Exclusive Solutions LLC |
deb@piciowa.com |
Norwalk |
Polk |
Ia |
Debra Stratton |
Kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jovan Guerrero dba Exclusive SOlutions LLC |
jovanguerrero29@gmail.com |
self |
Norwalk |
Poik |
Iowa |
Debra Stratton |
Kelly Denger |
Signed |
1953 |
2023-12-12 15:38 |
Anonymous (not verified) |
94.188.207.226 |
Ryan Gideon |
Proprietorship |
9320 Elmcrest Dr Norwalk, Ia 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-12 |
Ryan Gideon |
rgid8403@gmail.com |
Norwalk |
Warren |
IA |
Jim Lane |
Jim Lane |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Gideon |
rgid8403@gmail.com |
Owner |
Norwalk |
Warren |
IA |
jim Lane |
Jim Lane |
Signed |
1959 |
2023-12-15 13:32 |
Anonymous (not verified) |
94.188.205.169 |
DeFreeceBuilt LLC |
Limited Liability Company |
216 Rellim Dr Norwalk, IA 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-15 |
Dylan DeFreece |
dylan@defreecebuiltia.com |
Norwalk |
Warren |
Iowa |
Abigail DeFreece |
Ricki Schroeder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dylan DeFreece |
dylan@defreecebuiltia.com |
N/A |
Norwalk |
Warren |
Iowa |
Abigail DeFreece |
Ricki Schroeder |
Signed |
2000 |
2024-01-26 10:05 |
Anonymous (not verified) |
94.188.205.177 |
Nick Myers Construction |
Proprietorship |
4736 Candlewick Drive, Norwalk, IA 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-26 |
Nicholas Myers |
myersnicholasj@gmail.com |
Norwalk |
Warren |
Iowa |
John Myers |
Brenda Myers |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas Myers |
nickmyersconstruction@gmail.com |
Owner |
Norwalk |
IA |
IA |
John Myers |
Brenda Myers |
Signed |
2058 |
2024-02-26 16:32 |
Anonymous (not verified) |
94.188.207.224 |
performance gutter |
Proprietorship |
PO BOX 306, NORWALK IOWA 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-26 |
RICHARD BAINTER |
RWBNJ50@AOL.COM |
NORWALK |
WARREN |
IOWA |
DYLAN LANE |
JAMES LANE |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RICHARD BAINTER |
RWBNJ50@AOL.COM |
OWNER |
NORWALK |
WARREN |
IOWA |
DYLAN LANE |
JAMES LANE |
Signed |
2167 |
2024-04-21 22:01 |
Anonymous (not verified) |
94.188.205.177 |
The Duerson Corportaion |
Proprietorship |
601 1st Ave N, 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. |
2024-04-21 |
Nicholas John Myers |
myersnicholasj@gmail.com |
Norwalk |
IA |
United States |
Theresa Myers |
Bradyn Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas John Myers |
myersnicholasj@gmail.com |
Owner |
Norwalk |
IA |
United States |
Theresa Myers |
Bradyn Smith |
Signed |
332 |
2020-12-04 10:57 |
Anonymous (not verified) |
66.188.136.150 |
Ron's Trucking LLC |
Limited Liability Company |
16007 Oak Avenue, Oak Forrest, IL 60452 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-04 |
Ronald Clark Jr. |
kschumacher@tricorinsurance.com |
Oak Forrest |
Cook |
IL |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ron's Trucking LLC |
kschumacher@tricorinsurance.com |
Same |
Oak Forrest |
Cook |
IL |
Russell Masartis |
Nancy Wortley |
Signed |
1014 |
2022-03-28 16:33 |
Anonymous (not verified) |
76.102.203.170 |
Self - Maryssa Wanlass |
Proprietorship |
871 Wood St. Oakland CA 94607 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-01 |
Maryssa Wanlass |
maryssa.wanlass@alli-center.com |
Oakland |
Alameda |
California |
Mark Vashro |
Don Naughton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maryssa Wanlass |
maryssa.wanlass@alli-center.com |
Self |
Oakland |
Alameda |
California |
Mark Vashro |
Don Naughton |
Signed |
2033 |
2024-02-07 11:38 |
Anonymous (not verified) |
94.188.205.168 |
JENKINS CONSTRUCTION |
Proprietorship |
315 NORTH MAIN STREET, P.O. BOX 124, ODEBOLT, IA 51458 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-07 |
DENNIS CHARLES JENKINS |
dcjmjenkins@yahoo.com |
ODEBOLT |
SAC |
IOWA |
ROBERT EUGENE BELT |
JOHN CLARENCE OLERICH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
DENNIS CHARLES JENKINS |
dcjmjenkins@yahoo.com |
SELF |
ODEBOLT |
SAC |
IOWA |
ROBERT EUGENE BELT |
JOHN CLARENCE OLERICH |
Signed |
53 |
2020-02-06 11:09 |
Anonymous (not verified) |
65.100.22.228 |
Bostian Captioning Service, Inc. |
Proprietorship |
712 8th Avenue 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. |
2020-02-06 |
Dana Bostian |
danabostian@msn.com |
Oelwein |
IA |
United States |
Lynne Koch |
Billie Winters |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dana Bostian |
danabostian@msn.com |
President of Proprietorship |
Oelwein |
IA |
United States |
Lynne Koch |
Billie Winters |
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 |
1045 |
2022-04-13 09:55 |
Anonymous (not verified) |
192.119.237.126 |
BARGAIN HOUSE |
Proprietorship |
11 S FREDERICK AVE, OELWEIN, IA 50662 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-13 |
RICHARD M. BECKER |
SHELBY@CIOIA.COM |
HAZLETON |
BUCHANAN |
IOWA |
SHELBY S. WILLIAMS |
BOBBIE J. BERGAN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RICHARD M. BECKER |
SHELBY@CIOIA.COM |
OWNER |
OELWEIN |
FAYETTE |
IOWA |
SHELBY S. WILLIAMS |
BOBBIE J. BERGAN |
Signed |
1654 |
2023-05-19 11:09 |
Anonymous (not verified) |
94.188.205.176 |
ST SULLIVAN CONSTRUCTION COMPANY |
Proprietorship |
1614 100TH ST., OELWEIN, IOWA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-19 |
STEVE SULLIVAN |
sullycon@msn.com |
Oelwein |
Fayette |
Iowa |
Bobbie J Bergan |
Shelby Williams |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
STEVE SULLIVAN |
sullycon@msn.com |
OWNER |
OELWEIN |
FAYETTE |
IOWA |
BOBBIE J BERGAN |
SHELBY WILLIAMS |
Signed |
42 |
2020-01-24 12:26 |
Anonymous (not verified) |
173.24.181.211 |
MIKE EDDY |
Proprietorship |
PO BOX 437 OKOBOJI, IA 51355 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-22 |
MIKE EDDY |
joel@walkerinsuranceia.com |
OKOBOJI |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MIKE EDDY |
JOEL@WALKERINSURANCEIA.COM |
OWNER |
OKOBOJI |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |