1407 |
2023-01-04 13:26 |
Anonymous (not verified) |
67.55.135.18 |
Duncan Customs LLC |
Limited Liability Company |
8857 Union Cir. Cedar Falls, IA 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-04 |
Rory Eugene Duncan |
ddmusicsolutions@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Travis Duncan |
Alethea Duncan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rory Duncan |
ddmusicsolutions@gmail.com |
self |
Cedar Falls |
Black Hawk |
Iowa |
Travis Duncan |
Alethea Duncan |
Signed |
1657 |
2023-05-22 14:31 |
Anonymous (not verified) |
94.188.207.224 |
Collum Plumbing, LLC |
Limited Liability Company |
610 West 20th, Cedar Falls, IA 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-22 |
Stephen Collum |
collumplumbing@cfu.net |
Cedar Falls |
Iowa |
United States |
Mike Thode |
Linda Thode |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stephen Collum |
collumplumbing@cfu.net |
Owner/Member of LLC |
Cedar Falls |
Black Hawk |
Iowa |
Mike Thode |
Linda Thode |
Signed |
1744 |
2023-07-13 13:52 |
Anonymous (not verified) |
94.188.205.176 |
T-Rex Construction LLC |
Limited Liability Company |
1203 Bluegrass Circle Unit 4 Cedar Falls Iowa 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-12 |
Claudia Rodriguez De Nunez |
t.rexbigbiz@gmail.com |
CEDAR FALLS |
IA |
United States |
Ana Chavez |
Alicia Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Guillermo Nunez |
claudia.rodriguez.213@gmail.com |
Spouse |
CEDAR FALLS |
IA |
United States |
Alicia Garcia |
Ana Chavez |
Signed |
1817 |
2023-08-24 12:29 |
Anonymous (not verified) |
94.188.207.223 |
Global Roofing LLC |
Limited Liability Company |
504 Heritage Rd Cedar Falls IA 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-20 |
Jose Rafael Delgado Marin |
grjrd808504@outlook.com |
Cedar Falls |
Black Hawk |
Iowa |
Noemi Guerrero |
Andres B Montoya |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Rafael Delgado |
grjrd808504@outlook.com |
member |
Cedar Falls |
Black Hawk |
Iowa |
Noemi Guerrero |
Andres B Montoya |
Signed |
1818 |
2023-08-25 15:16 |
Anonymous (not verified) |
94.188.207.224 |
Global Roofing LLC |
Limited Liability Company |
504 Heritage Rd Cedar Falls IA 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-20 |
Yenifer Yomara Hernandez Solis |
Grjrd808504@outlook.com |
Cedar Falls |
Black Hawk |
Iowa |
Noemi Guerrero |
Andres B Montoya |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Rafael Delgado Marin |
Grjrd808504@outlook.com |
member |
Cedar Falls |
Black Hawk |
Iowa |
Noemi Guerrero |
Andres B Montoya |
Signed |
1928 |
2023-11-29 21:48 |
Anonymous (not verified) |
94.188.205.168 |
Iowa Evolution Constuction |
Partnership |
1203 Bluegrass Cir |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-01 |
Claudia Rodriguez |
claudia.rodriguez.213@gmail.com |
CEDAR FALLS |
IA |
United States |
Guillermo Nunez |
Blanca rodriguez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Claudia Rodriguez |
claudia.rodriguez.213@gmail.com |
Owner |
CEDAR FALLS |
IA |
United States |
Guillermo Nunez |
Blanca Rodriguez |
Signed |
2165 |
2024-04-19 14:05 |
Anonymous (not verified) |
94.188.207.225 |
Apex Striping LLC |
Limited Liability Company |
1325 Western Ave, cedar Falls, IA. 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-19 |
Chaz Ernest Torres |
admin@apexstripingia.com |
Cedar Falls |
Blackhawk |
Iowa |
Theresa Jo Torres |
Eloy James Torres |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chaz Ernest Torres |
admin@apexstripingia.com |
Self |
Cedar Falls |
Blackhawk |
Iowa |
Theresa Jo Torres |
Eloy James Torres |
Signed |
2178 |
2024-04-25 10:56 |
Anonymous (not verified) |
94.188.205.176 |
Loonpa Landscaping LLC |
Limited Liability Partnership |
5309 Red Oak Ln Cedar Falls, IA 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2024-04-25 |
Daniel J White |
danny@barerootslawn.care |
Cedar Falls |
Black Hawk |
iowa |
Kari White |
James White |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Daniel J White |
danny@barerootslawn.care |
Owner |
Cedar Falls |
Black Hawk |
Iowa |
James White |
Kari White |
Signed |
2179 |
2024-04-25 10:58 |
Anonymous (not verified) |
94.188.205.177 |
Loonpa Landscaping LLC |
Limited Liability Partnership |
5309 Red Oak Ln Cedar Falls, IA 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2024-04-25 |
Brent Barloon |
Brent@barerootslawn.care |
WAterloo |
Black Hawk |
Iowa |
James White |
Kari White |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Daniel White |
danny@barerootslawn.care |
Owner |
Cedar Falls |
Black Hawk |
Iowa |
James White |
Kari White |
Signed |
2183 |
2024-04-26 14:49 |
Anonymous (not verified) |
94.188.205.168 |
Cory's Painting LLC |
Limited Liability Company |
Po Box 1161 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-01 |
Jared Birkenholz |
jareddrewb@gmail.com |
CEDAR FALLS |
IA |
United States |
Colton Blue |
Kari Houle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cory Koger |
coryspainting@gmail.com |
Self |
CEDAR FALLS |
IA |
United States |
Colton Blue |
Kari Houle |
Signed |
2184 |
2024-04-26 15:03 |
Anonymous (not verified) |
94.188.205.166 |
Cory's Painting LLC |
Limited Liability Company |
Po Box 1161, Cedar Falls, Iowa 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-15 |
Joseph Abrahamson |
abrahamsonjd95@gmail.com |
Readlyn |
Bremer |
United States |
Colton Blue |
Kari Houle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cory Koger |
coryspainting@gmail.com |
Self |
Cedar Falls |
Blackhawk |
Iowa |
Colton Blue |
Kari Houle |
Signed |
62 |
2020-02-17 06:55 |
Anonymous (not verified) |
173.31.111.29 |
Pa's Construction LLC |
Limited Liability Company |
2350 Glass Rd NE, Cedar Rapids, IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-17 |
Gregory Daniel Saunders |
gsaunders.pas@gmail.com |
CEDAR RAPIDS |
IOWA |
United States |
Laura Sturm |
Chad Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Saunders |
dan2112411@yahoo.com |
Owner |
Cedar Rapids |
Linn |
Iowa |
Walt Cheney |
Mike Broghammer |
Signed |
204 |
2020-07-15 11:21 |
Anonymous (not verified) |
63.152.54.222 |
Tim Duggan |
Limited Liability Company |
1405 1st St. SW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-15 |
Timothy M Duggan |
tdc.inc30@gmail.com |
Cedar Rapids |
Iowa |
United States |
Joe Willis |
Andrew Anson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy M Duggan |
tdc.inc30@gmail.com |
President |
Cedar Rapids |
Iowa |
United States |
Joe Willis |
Andrew Anson |
Signed |
326 |
2020-11-25 08:39 |
Anonymous (not verified) |
66.188.136.150 |
Robert Barbaris |
Proprietorship |
1104 8th St SE, Cedar Rapids, IA 52401 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-25 |
Robert Barbaris |
kschumacher@tricorinsurance.com |
Cedar Rapids |
Linn |
IA |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert Barbaris |
kschumacher@tricorinsurance.com |
Same |
Cedar Rapids |
Linn |
IA |
Russell Masartis |
Nancy Wortley |
Signed |
348 |
2020-12-31 14:09 |
Anonymous (not verified) |
66.129.217.166 |
Premier Plus LLC |
Limited Liability Company |
1930 St Andrews Crt NE, Suite A, Cedar Rapids, IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-01 |
Cerby Newton |
tonypauljohnson@yahoo.com |
Cedar Rapids |
IA |
United States |
Olvin Lanza |
Anthony Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cerby Newton |
tonypauljohnson@yahoo.com |
Owner |
Cedar Rapids |
IA |
United States |
Anthony Johnson |
Olvin Lanza |
Signed |
522 |
2021-05-17 20:27 |
Anonymous (not verified) |
50.81.4.25 |
Crew Cut Lawn Care |
Limited Liability Company |
7820 1st Ave NW Cedar Rapids, IA 52405 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-17 |
Rupert McKendly Ellis |
wideglide94@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Adrian Pink |
Lorraine Ellis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rupert M Ellis |
wideglide94@gmail.com |
Owner |
Cedar Rapids |
Linn |
IA |
Adrian Pink |
Lorraine |
Signed |
714 |
2021-11-05 11:16 |
Anonymous (not verified) |
209.252.172.87 |
Branson Bult - Bults Flooring |
Proprietorship |
440 Memorial Dr Se Cedar Rapids, Ia 52403 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-16 |
Branson Bult |
bultsfloorcovering@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Branson Bult |
bultsfloorcovering@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
715 |
2021-11-05 11:27 |
Anonymous (not verified) |
209.252.172.87 |
Ken Clifford |
Proprietorship |
132121st Ave SW Cedar Rapids, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-18 |
Ken Clifford |
ken40406108@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ken Clifford |
ken40406108@gmail.com |
Self Employer |
Cedar Rapids |
Linn |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
719 |
2021-11-05 13:48 |
Anonymous (not verified) |
174.198.66.202 |
James Johnson Ace Floor Guys |
Proprietorship |
521 29th st NE Cedar Rapids, Ia 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-13 |
James Johnson |
acefloorguysia@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Johnson |
acefloorguysia@gmail.com |
Self Employed |
Cedar Rapids |
Linn |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
722 |
2021-11-05 14:07 |
Anonymous (not verified) |
209.252.172.87 |
Jeremiah Lunsford |
Proprietorship |
624 Carroll Dr SE, Cedar Rapids, IA 52403 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-10 |
Jeremiah Lundsford |
jjaylunsford@gmail.com |
Cedar Paids |
Linn |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeremiah Lunsford |
jjaylunsford@gmail.com |
Self Employed |
Cedar Rapids |
Linn |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
725 |
2021-11-05 14:32 |
Anonymous (not verified) |
174.198.66.202 |
Jay Schulte |
Proprietorship |
7530 Prairie Hawk Dr Sw, Cedar Rapids, Ia 52404 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Jay Schulte |
schultejay@Hotmail.com |
Cedar Rapids |
Linn |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jay Schulte |
schultejay@hotmail.com |
Self Employed |
Cedar Rapids |
Linn |
Ia |
Sarah Coberley |
Heather Howell |
Signed |
727 |
2021-11-05 14:46 |
Anonymous (not verified) |
174.198.66.202 |
Bret Swift Swift Enterprises |
Proprietorship |
2240 Coldstream Drive NE, Cedar Rapids, Ia 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-13 |
Brett Swidt |
swiftenterprises@me.com |
Cedar Rapids |
Linn |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bret Swift |
swiftenterprises@me.com |
Self Employed |
Cedar Rapids |
Linn |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
795 |
2021-12-15 07:47 |
Anonymous (not verified) |
173.22.84.26 |
LAMPE APPLIANCE SERVICE, Inc |
Proprietorship |
210 29TH ST 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. |
2021-12-15 |
Douglas James Lampe |
lampeappliance@gmail.com |
CEDAR RAPIDS |
IA |
IA |
John Kenneth Lampe |
Kenneth Roman Lampe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Douglas James Lampe |
lampeappliance@gmail.com |
Vice President |
Cedar Rapids |
Linn |
Iowa |
John Kenneth Lampe |
Kenneth Roman Lampe |
Signed |
796 |
2021-12-15 07:58 |
Anonymous (not verified) |
173.22.84.26 |
LAMPE APPLIANCE SERVICE, Inc |
Proprietorship |
210 29TH ST 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. |
2021-12-15 |
John Kenneth Lampe |
lampeappliance@gmail.com |
CEDAR RAPIDS |
Linn |
IA |
Douglas James Lampe |
Kenneth Roman Lampe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Douglas James Lampe |
lampeappliance@gmail.com |
Vice President |
CEDAR RAPIDS |
IA |
Linn |
Douglas James Lampe |
Kenneth Roman Lampe |
Signed |
797 |
2021-12-15 08:01 |
Anonymous (not verified) |
173.22.84.26 |
LAMPE APPLIANCE SERVICE, Inc |
Proprietorship |
210 29TH ST 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. |
2021-12-15 |
Kenneth Roman Lampe |
lampeappliance@gmail.com |
CEDAR RAPIDS |
Linn |
IA |
Douglas James Lampe |
John Kenneth Lampe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Douglas James Lampe |
lampeappliance@gmail.com |
Vice President |
CEDAR RAPIDS |
Linn |
Iowa |
Douglas James Lampe |
John Kenneth Lampe |
Signed |
798 |
2021-12-15 08:03 |
Anonymous (not verified) |
173.22.84.26 |
LAMPE APPLIANCE SERVICE, Inc |
Proprietorship |
210 29TH ST 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. |
2021-12-15 |
Jared J Lampe |
lampeappliance@gmail.com |
CEDAR RAPIDS |
Linn |
IA |
Douglas James Lampe |
John Kenneth Lampe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Douglas James Lampe |
lampeappliance@gmail.com |
Vice President |
CEDAR RAPIDS |
Linn |
Iowa |
Douglas James Lampe |
John Kenneth Lampe |
Signed |
824 |
2022-01-06 20:57 |
Anonymous (not verified) |
209.252.175.92 |
Rottweiler Remodel & Repair LLC |
Limited Liability Company |
1503 10th Ave Sw Cedar Rapids Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-06 |
Zechariah Robert DeLaVergne |
rottweilerremodel@gmail.com |
Cedar Rapids |
Linn County |
Iowa |
Kathy Maxine Morgan |
Daisha Rae Gonzalez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Zechariah DeLaVergne |
rottweilerremodel@gmail.com |
Owner |
Cedar Rapids |
Linn County |
Iowa |
Kathy Maxine Morgan |
daisha rae gonzalez |
Signed |
862 |
2022-01-27 12:02 |
Anonymous (not verified) |
174.198.81.166 |
Big Bear Construction,LLC |
Limited Liability Company |
4508 Hiawatha Ave NE Cedar Rapids, IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-27 |
Michael Allen Becker |
mike4bbc@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Kenny McCracken |
Corey Becker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kevin Paul Becker jr |
kbeckerbbc@gmail.com |
Brother/partner |
Cedar Rapids |
Linn |
Iowa |
Kenny McCracken |
Corey Becker |
Signed |
863 |
2022-01-27 12:13 |
Anonymous (not verified) |
174.198.81.166 |
Big Bear Construction llc |
Limited Liability Company |
4508 Hiawatha Ave ne Cedar Rapids iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-27 |
Kevin Paul Becker jr |
kbeckerbbc@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Kenny McCracken |
Corey Becker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Allen Becker |
mike4bbc@gmail.com |
Brother/Partner |
Cedar Rapids |
Linn |
Iowa |
Kenny McCracken |
Corey Becker |
Signed |
875 |
2022-01-31 11:00 |
Anonymous (not verified) |
173.31.102.93 |
Jhk Construction LLC |
Limited Liability Company |
6203 Casey Ct NE cedar Rapids Iowa 52411 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-31 |
Edward Charles Loehr |
jhkcostruction10@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Leanne M Loehr |
Autumn G Loehr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jhk Construction LLC |
jhkconstruction10@gmail.com |
Owner |
Cedar Rapids |
Linn |
Iowa |
Leanne M Loehr |
Autumn G Loehr |
Signed |
896 |
2022-02-04 11:58 |
Anonymous (not verified) |
198.167.180.146 |
Northtowne Market Lot 7, LLC |
Limited Liability Company |
1005 Blairs Ferry Road NE, Cedar Rapids, IA 52404 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Benjamin Wickum |
bwickum@collinscu.org |
CEDAR RAPIDS |
Linn |
Iowa |
Jody Comried |
Pat Milke |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Benjamin Wickum |
bwickum@collinscu.org |
Manager |
Cedar Rapids |
Linn |
Iowa |
Jody Comried |
Pat Milke |
Signed |
908 |
2022-02-09 15:06 |
Anonymous (not verified) |
63.152.66.183 |
Shear Texture |
Limited Liability Company |
1427 A Ave NW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-09 |
Wendy Kiser |
kiser187@msn.com |
Cedar Rapids |
Linn |
Iowa |
Shelly Wehr |
Kimberly Erickson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wendy Kiser |
kiser187@msn.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Shelly Wehr |
Kimberly Erickson |
Signed |
979 |
2022-03-15 13:48 |
Anonymous (not verified) |
72.255.78.146 |
Custom Climates |
Partnership |
3305 Highway 1 SW Ste 9A 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. |
2022-03-15 |
Allen Nichols |
ranichols4@gmail.com |
CEDAR RAPIDS |
Iowa |
IA |
Rose Nichols |
Rose Nichols |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Allen Nichols |
ranichols4@gmail.com |
spouse |
CEDAR RAPIDS |
Iowa |
IA |
Rose Nichols |
Rose Nichols |
Signed |
1029 |
2022-04-04 12:46 |
Anonymous (not verified) |
174.215.242.124 |
Bonnie Seely |
Proprietorship |
43 rainbow court se Cedar Rapids Iowa 52403 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-04 |
Bonnie Elizabeth seely |
bseely4@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Mikaela Seely |
Noah seely |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bonnie Seely |
bseely4@gmail.com |
Self |
Cedar Rapids |
IA |
United States |
Mikaela Seely |
Noah Seely |
Signed |
1088 |
2022-05-04 16:00 |
Anonymous (not verified) |
50.80.16.238 |
American Gutter Company LLC |
Proprietorship |
2015 Andrew Charles Dr NW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-04 |
John Kuper |
american.guttercompanyllc@gmail.com |
CEDAR RAPIDS |
Linn |
IA |
Kirstin Hagerty |
Vic Kuper |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Kuper |
american.guttercompanyllc@gmail.com |
Owner |
CEDAR RAPIDS |
Linn |
IA |
Kirstin Hagerty |
Vic Kuper |
Signed |
1093 |
2022-05-12 06:32 |
Anonymous (not verified) |
50.80.25.116 |
Beast Construction LLC |
Limited Liability Company |
1025 O Ave NW, Cedar Rapids, IA 52405 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-01 |
Catarino Martinez Alvarez - H&C Roofing LLC |
handc.rconst@outlook.com |
North Liberty |
Johnson |
Iowa |
Evelyn Lagos |
Edgardo Hernandez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Greg Saunders |
Gsaunders@beastconstructioncr.com |
Owner |
Cedar Rapids |
Linn |
Iowa |
Laura Sturm |
Joanie Lacayo |
Signed |
1108 |
2022-05-16 16:14 |
Anonymous (not verified) |
4.4.30.34 |
David Sickels |
Proprietorship |
2221 Radcliffe Drive SW, Cedar Rapids, IA 52404 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-16 |
David Sickels |
glsickels@gmail.com |
Cedar Rapids |
IA |
United States |
Chad Allen Taylor |
Steven Thomas Dunn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Allen Sickels |
glsickels@gmail.com |
self |
Cedar Rapids |
Linn |
Iowa |
Chad Allen Taylor |
Steven Thomas Dunn |
Signed |
1129 |
2022-05-26 13:34 |
Anonymous (not verified) |
172.58.227.18 |
Jonathan M Ramirez |
Proprietorship |
834 20th STREET SE. Cedar Rapids IA 53403 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-26 |
Jonathan M Ramirez |
jon.hodgecma@gmail.com |
Cedar Rapids |
Linn |
IA |
Audrey Randle-EL |
Jeffrey M Ramirez Jr. |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jonathan Ramirez |
linncountyramirez@gmail.com |
Owner |
Cedar Rapids |
Linn |
Iowa |
Audrey Randle-EL |
Jeffrey Ramirez Jr |
Signed |
1130 |
2022-05-26 13:34 |
Anonymous (not verified) |
172.58.227.18 |
Jonathan M Ramirez |
Proprietorship |
834 20th STREET SE. Cedar Rapids IA 53403 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-26 |
Jonathan M Ramirez |
jon.hodgecma@gmail.com |
Cedar Rapids |
Linn |
IA |
Audrey Randle-EL |
Jeffrey M Ramirez Jr. |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jonathan Ramirez |
linncountyramirez@gmail.com |
Owner |
Cedar Rapids |
Linn |
Iowa |
Audrey Randle-EL |
Jeffrey Ramirez Jr |
Signed |
1138 |
2022-06-01 15:01 |
Anonymous (not verified) |
173.18.233.175 |
Roy Rohwedder |
Proprietorship |
296 24th Ave SW Cedar Rapids, IA 52404 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Roy h Rohwedder |
rohwedder.roy@yahoo.com |
Cedar Rapids |
linn |
iowa |
Cash Rohwedder |
Brian Ashlock |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Ashlock |
brian@tricounty-iowa.com |
Genaral Manager |
Cedar Rapids |
Linn |
IOWA |
Branden Peters |
Jenny Vaske |
Signed |
1145 |
2022-06-07 11:14 |
Anonymous (not verified) |
173.30.72.62 |
Swifty Enterprises |
Limited Liability Company |
1134 Capri Drive NE, Cedar Rapids, IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-07 |
Daniel Tabaka |
dmtabaka1@gmail.com |
Cedar Rapids |
Linn |
IA |
Wilma Janacek |
Fredrick Janacek |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Tabaka |
dmtabaka1@gmail.copm |
Self |
Cedar Rapids |
Linn |
IA |
Wilma Janacek |
Fredrick Janacek |
Signed |
1182 |
2022-07-06 13:40 |
Anonymous (not verified) |
50.80.25.116 |
Beast Construction LLC |
Limited Liability Company |
1025 O Ave NW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-11 |
Gilberto Vasquez (GV Construction LLC) |
Normambazquez@gmail.com |
Iowa City |
IA |
United States |
Pedro Pinto |
Rafael Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Greg Saunders |
gsaunders@beastconstructioncr.com |
Owner |
CEDAR RAPIDS |
IA |
United States |
Laura Saunders |
Joanie Lacayo |
Signed |
1229 |
2022-07-26 15:56 |
Anonymous (not verified) |
173.31.102.238 |
Rai Neu Jo LLC |
Limited Liability Company |
957 Westwood Dr NW Cedar Rapids, Iowa 52405 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-26 |
Craig Edward Johnson |
cejohnson119@yahoo.com |
Cedar Rapids |
Linn |
Iowa |
Becky Lynn Johnson |
Patricia Ann Coghlan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Craig Edward Johnson |
cejohnson119@yahoo.com |
Same person |
Cedar Rapids |
Linn |
Iowa |
Becky Lynn Johnson |
Patricia Ann Coghlan |
Signed |
1234 |
2022-08-01 16:55 |
Anonymous (not verified) |
50.80.97.166 |
Joshua Schumacher |
Proprietorship |
5801 timber creek rd 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. |
2022-08-01 |
Josh Schumacher |
amjs2003@centurylink.net |
Cedar Rapids |
Iowa |
Iowa |
Karen Meroshek |
Philip McCurdy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Schumacher |
amjs2003@centurylink.net |
Self |
Cedar Rapids |
Iowa |
Iowa |
Katen Meroshek |
Philip McCurdy |
Signed |
1237 |
2022-08-01 22:40 |
Anonymous (not verified) |
50.80.97.239 |
Andy Fiala |
Proprietorship |
1628 34th St. 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. |
2022-08-01 |
Andy W Fiala |
fialaandy1@gmail.com |
Cedar Rapids |
IA |
United States |
John A Hasson |
Scott M Fiala |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andy W Fiala |
fialaandy1@gmail.com |
Owner |
Cedar Rapids |
IA |
United States |
John A Hasson |
Scott M Fiala |
Signed |
1251 |
2022-08-11 09:11 |
Anonymous (not verified) |
174.255.1.226 |
Two Crew Remodeling and Maintenance |
Limited Liability Partnership |
11 C Ave Newhall, Iowa, 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. |
(1) I am not electing the employers’ liability coverage. |
2022-08-11 |
Trenten John Schafer |
Twocrewremodeling@gmail.com |
Newhall |
Benton |
Iowa |
Joeseph Allen Alger |
Glenn Mitchel Kieler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan McArtor |
Mcartorjordan@gmail.com |
Part owner |
cedar rapids |
CEDAR RAPIDS, IA (Inside) LINN |
Iowa |
Joeseph Allen Alger |
Glenn Mitchel Kieler |
Signed |
1279 |
2022-08-22 13:17 |
Anonymous (not verified) |
50.83.54.168 |
Essex Family Construction |
Limited Liability Company |
290 Monmouth St SW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-22 |
Niki Essex |
essexfamilycontruction@outlook.com |
Cedar Rapids |
IA |
IA |
Josh Lasond |
Jordan Nisiewicz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Niki Essex |
essexfamilycontruction@outlook.com |
same |
Cedar Rapids |
Iowa |
Iowa |
Josh Lasond |
Jordan Nisiewicz |
Signed |
1321 |
2022-09-26 08:16 |
Anonymous (not verified) |
204.141.215.159 |
Leaf filter |
Limited Liability Company |
615 J Ave NE Cedar Rapids, Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-26 |
Dustin Hansen |
dhansen0925@gmail.com |
Marion |
Linn |
Iowa |
Audrianna Cleveland |
Trevor Frondle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Leaf filter |
sewell@leafhome.com |
N/a |
Cedar rapids |
Linn |
Iowa |
N/a |
N/a |
Signed |
1332 |
2022-10-12 20:44 |
Anonymous (not verified) |
209.252.174.114 |
Nelson Tile |
Proprietorship |
300 Shetland Dr. N.W. Cedar Rapids, Ia. 52405 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-12 |
Bruce Allen Nelson |
sherylnelson15@yahoo.com |
Cedar Rapids |
Linn |
Iowa |
Sheryl Marie Nelson |
Roger Eugene Nelson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bruce Allen Nelson |
sherylnelson@yahoo.com |
Owner,operator / same |
Cedar Rapids |
Linn |
Iowa |
Sheryl Marie Nelson |
Roger Eugene Nelson |
Signed |
1351 |
2022-10-31 16:36 |
Anonymous (not verified) |
75.231.74.186 |
Spencer C Nash LLC |
Limited Liability Company |
4233 Pineview Dr NE, Cedar Rapids, IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-31 |
Spencer Nash |
spencer@optionsexteriors.com |
Cedar Rapids |
Linn County |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Spencer Nash |
spencer@optionsexteriors.com |
Owner/Self |
Cedar Rapids |
Linn County |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
1366 |
2022-11-10 09:33 |
Anonymous (not verified) |
172.58.87.232 |
Blackstone Handy Services, LLC |
Limited Liability Company |
1807 B Avenue Northeast |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-10 |
jovan walton |
blackstonehandyservices@gmail.com |
Cedar Rapids |
IA |
United States |
Mekaylah K. Stevens |
Dominique T. Walton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
jovan walton |
blackstonehandyservices@gmail.com |
Self |
Cedar Rapids |
Linn |
United States |
Mekaylah K. Stevens |
Dominique T. Walron |
Signed |
1375 |
2022-11-18 10:21 |
Anonymous (not verified) |
166.181.87.119 |
Heff Built Construction LLC |
Limited Liability Company |
1403 Kodiak Dr NW Cedar Rapids, IA 52405 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-18 |
Jacob Heffernen |
jheffernen@gmail.com |
Cedar Rapids |
Linn |
IA |
Kyle Reid |
Amanda Frese |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jacob Heffernen |
jheffernen@gmail.com |
N/A |
Cedar Rapids |
Linn |
IA |
Kyle Reid |
Amanda Frese |
Signed |
1376 |
2022-11-18 10:22 |
Anonymous (not verified) |
166.181.87.119 |
Ashley Heffernen |
Proprietorship |
4009 Majestic Ct NE Cedar Rapids Iowa 52411 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-18 |
Ashley Rae Heffernen |
ashley.heffernen@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Kyle Reid |
Amanda Frese |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ashley Rae Heffernen |
ashley.heffernen@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Kyle Reid |
Amanda Frese |
Signed |
1408 |
2023-01-04 16:12 |
Anonymous (not verified) |
50.82.188.217 |
Guerrero Masonry |
Proprietorship |
5003 Keystone Rdg SE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-01 |
Jaime Guerrero |
jaime.guerrero@mchsi.com |
Cedar Rapids |
IA |
United States |
Susan Bender |
Larry Bender |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jaime Guerrero |
jaime.guerrero@mchsi.com |
self |
CEDAR RAPIDS |
Linn |
Iowa |
Susan Bender |
Larry Bender |
Signed |
1409 |
2023-01-05 11:55 |
Anonymous (not verified) |
173.23.88.7 |
Top tier gutter systems llc |
Limited Liability Company |
405a 1st Ave sw Cedar Rapids, ia |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-05 |
Rocky layne smith |
toptierguttersystems@yahoo.com |
Cedar Rapids |
Linn |
IA |
Faye momodu |
Rocky smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rocky smith |
toptierguttersystems@yahoo.com |
Self |
Cedar Rapids |
Linn |
IA |
Faye momodu |
Derrick |
Signed |
1446 |
2023-02-08 16:49 |
Anonymous (not verified) |
94.188.207.228 |
ZAHID ALI |
Limited Liability Company |
3245 SOUTHGATE PL SW, IOWA 52404 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-10 |
ZAHID ALI |
ali@americaninncid.com |
CEDAR RAPIDS |
USA |
IOWA |
ZAHID ALI |
ZAHID ALI |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
ZAHID ALI |
ali@americaninncid.com |
self |
cedar rapids |
usa |
iowa |
ZAHID ALI |
ZAHID ALI |
Signed |
1455 |
2023-02-15 11:44 |
Anonymous (not verified) |
94.188.205.177 |
Bruce A. Nelson |
Proprietorship |
300 Shetland Dr Nw Cedar Rapids, IA 52405 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-15 |
Bruce A. Nelson |
sherylnelson15@yahoo.com |
Cedar Rapids |
Linn |
Iowa |
Lynn M Haigh |
David Reibsamen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sheryl Nelson |
sherylnelson15@yahoo.com |
Wife |
Cedar Rapids |
Linn |
Iowa |
Lynn M. Haigh |
David Reibsamen |
Signed |
1480 |
2023-02-24 08:54 |
Anonymous (not verified) |
94.188.205.176 |
Shear Texture |
Limited Liability Company |
2000 Wiley Blvd SW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-24 |
Wendy Kiser |
kiser187@msn.com |
Cedar Rapids |
Linn |
Iowa |
Kim Erickson |
Shauna Whitaker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wendy Kiser |
kiser187@msn.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Kim Erickson |
Shauna Whitaker |
Signed |
1533 |
2023-03-25 10:24 |
Anonymous (not verified) |
94.188.207.226 |
Doug Uridil |
Proprietorship |
616 16th Street NE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-22 |
Doug Uridil |
douguridil@gmail.com |
Cedar Rapids |
United States |
IOWA |
Heidi Vincent |
Molly Coffman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Doug Uridil |
douguridil@gmail.com |
Self |
Cedar Rapids |
United status |
IOWA |
Heidi Vincent |
Molly Kaufman |
Signed |
1599 |
2023-04-25 14:38 |
Anonymous (not verified) |
94.188.207.229 |
luis contreras |
Proprietorship |
433 8th ave sw |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-25 |
luis contreras |
luisayala781@gmail.com |
cedar rapids |
linn |
iowa |
Ryan Klein |
Karina Jacobson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
luis contreras |
luisayala781@gmail.com |
N/A |
cedar rapids |
linn |
iowa |
Ryan Klein |
Karina Jacobson |
Signed |
1600 |
2023-04-25 14:38 |
Anonymous (not verified) |
94.188.207.223 |
martin garcia |
Proprietorship |
219 austin st sw cedar rapids 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. |
2023-04-25 |
martin garcia ayala |
martingarcia2100@gmail.com |
cedar rapids |
linn |
iowa |
Ryan Klein |
Karina Jacobson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
martin garcia ayala |
martingarcia2100@gmail.com |
na |
cedar rapids |
linn |
iowa |
Ryan Klein |
Karina Jacobson |
Signed |
1601 |
2023-04-25 14:38 |
Anonymous (not verified) |
94.188.207.230 |
francisco garcia |
Proprietorship |
388 lesley ln 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. |
2023-04-25 |
franscisco garcia |
frasicohinojosa@gmail.com |
cedar rapids |
linn |
iowa |
Ryan Klein |
Karina Jacobson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
francisco garcia |
frasicohinojosa@gmail.com |
N/A |
cedar rapids |
linn |
iowa |
Ryan Klein |
Karina Jacobson |
Signed |
1628 |
2023-05-09 08:00 |
Anonymous (not verified) |
94.188.205.175 |
Servin Drywall |
Proprietorship |
6311 Underwood Ave SW, Cedar Rapids, IA 52404 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-09 |
Arcel Servin |
arcelservin77@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Rolandas Bitanas |
Kirk Strunk |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Arcel Servin |
arcelservin77@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Rolandas Bitanas |
Kirk Strunk |
Signed |
1637 |
2023-05-10 15:39 |
Anonymous (not verified) |
94.188.207.230 |
Carly Roskop |
Proprietorship |
7706 Hampshire Ct NE Cedar Rapids, IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-10 |
Carly Roskop |
carlyroskop@gmail.com |
Cedar Rapids |
IA |
United States |
Dustin Roskop |
Tracy Petrak |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Carly Roskop |
carlyroskop@gmail.com |
Self |
Cedar Rapids |
IA |
United States |
Dustin Roskop |
Tracy Petrak |
Signed |
1645 |
2023-05-12 14:48 |
Anonymous (not verified) |
94.188.207.225 |
VL Drywall LLC |
Limited Liability Company |
1608 6th Ave SE Cedar Rapids |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-12 |
LESLIE LEYVA |
lleyva9696@gmail.com |
Cedar Rapids |
LINN |
Iowa |
Brad Bower |
Chris Hay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Leslie Leyva |
lleyva9696@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Chris Hay |
Brad Bower |
Signed |
1651 |
2023-05-16 22:18 |
Anonymous (not verified) |
94.188.205.175 |
Corridor Cleaning Services, LLC |
Limited Liability Company |
4621 Orchard Dr NW, Cedar Rapids, Iowa, 52405 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-11 |
Andrew Kleineck |
andrew@corridorcleaning.net |
Cedar Rapids |
Linn |
Iowa |
Cole Smith |
Suzanne Brue |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andrew Kleineck |
andrew@corridorcleaning.net |
LLC Member |
Cedar Rapids |
Linn |
Iowa |
Cole Smith |
Suzanne Brue |
Signed |
1769 |
2023-07-31 11:23 |
Anonymous (not verified) |
94.188.207.228 |
PSI LLC |
Limited Liability Company |
2765 N Center Point 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. |
2023-07-31 |
Esteici Reyes |
stacy0979@gmail.com |
Cedar Rapids |
Linn |
IA |
Jeffrey Ventura |
Eduardo Contreras |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Esteici Reyes |
stacy0979@gmail.com |
Owner |
Cedar Rapids |
Linn |
IA |
Jeffrey Ventura |
Eduardo Contreras |
Signed |
1789 |
2023-08-08 13:18 |
Anonymous (not verified) |
94.188.207.230 |
Corridor Construction Co., LLC |
Limited Liability Company |
P.O. Box 8540 Cedar Rapids, IA 52408 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Steven H. Miller |
jimfortmann60@gmail.com |
Cedar Rapids |
Linn |
IA |
James J. Fortmann |
Ruth Ann Beers |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steven H. Miller |
jimfortmann60@gmail.com |
Member |
Cedar Rapids |
Linn |
IA |
James J. Fortmann |
Ruth Ann Beers |
Signed |
1860 |
2023-10-04 14:31 |
Anonymous (not verified) |
94.188.207.229 |
Raymond Osbon |
Proprietorship |
1634 Park Towne LN 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. |
2023-10-04 |
Raymond Earl Osbon |
rozbon999@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Brandon Gibbs |
Jamie Fisher |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Raymond Earl Osbon |
rozbon999@gmail.com |
Myself |
Cedar Rapids |
Linn |
Iowa |
Brandon Gibbs |
Jamie Fisher |
Signed |
1876 |
2023-10-23 14:26 |
Anonymous (not verified) |
94.188.205.169 |
Magnus, LLC |
Limited Liability Company |
1120 2nd Street SE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-23 |
Kristina Link |
magnina@aol.com |
Cedar Rapids |
IA |
IA |
Shannon Thompson |
Jeff Spies |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kristina Link |
magnina@aol.com |
business owner |
Cedar Rapids |
Iowa |
Iowa |
Shannon Thompson |
Jeff Spies |
Signed |
1878 |
2023-10-26 09:06 |
Anonymous (not verified) |
94.188.205.168 |
Jones Facility Maintenance |
Limited Liability Company |
3929 Council Street NE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-25 |
Mason Jones |
jonesmason546@gmail.com |
Cedar Rapids |
IA |
United States |
Lindsey Jones |
Seth Wennermark |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mason Bradley Jones |
jonesmason546@gmail.com |
Owner |
Cedar Rapids |
IA |
United States |
Lindsey Jones |
Seth Wennermark |
Signed |
1879 |
2023-10-26 13:17 |
Anonymous (not verified) |
94.188.207.224 |
CR Exteriors |
Proprietorship |
1636 Parktown Ct NE Unit 9 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-26 |
corey becker |
cab222.ab@gmail.com |
cedar rapids |
linn |
iowa |
Brian Ashlock |
Brian Coover |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Corey Becker |
cab222.ab@gmail.com |
same |
Cedar Rapids |
Linn |
Iowa |
Brian Ashlock |
Brian Coover |
Signed |
1926 |
2023-11-29 10:45 |
Anonymous (not verified) |
94.188.207.224 |
M&M Janitorial LLC |
Limited Liability Company |
243 28th St Dr SE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-29 |
Mackenzie Willits |
mackenziewillits@gmail.com |
Cedar Rapids |
Linn |
United States |
Fransisco ruiz |
Alexander ruiz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Meyling willits |
mackenziewillits@gmail.com |
Owner |
cedar rapids |
Linn |
United States |
Alexander ruiz |
Francisco ruiz |
Signed |
1927 |
2023-11-29 13:13 |
Anonymous (not verified) |
94.188.207.228 |
Yaardman landscaping llc |
Limited Liability Company |
51623 se seet cedar rapids 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. |
2023-11-29 |
Adrian Pink |
Mr.Pink1118@gmail.com |
CEDAR RAPIDS |
IA |
United States |
Andrea Parker |
Kamar James |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adrian Pink |
Mr.Pink1118@gmail.com |
Owner |
CEDAR RAPIDS |
IA |
United States |
Andrea Parker |
Kamar James |
Signed |
1938 |
2023-12-05 11:54 |
Anonymous (not verified) |
94.188.207.225 |
Genius automotive |
Limited Liability Company |
51623 se seet cedar rapids iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-05 |
Adrian Pink |
Mr.Pink1118@gmail.com |
CEDAR RAPIDS |
IA |
United States |
Andrea Parker |
Kamar james |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adrian Pink |
Mr.Pink1118@gmail.com |
None |
CEDAR RAPIDS |
IA |
United States |
Andrea Parker |
Kamar James |
Signed |
1940 |
2023-12-05 15:11 |
Anonymous (not verified) |
94.188.207.227 |
David Sickels |
Proprietorship |
2221 Radcliffe drive s.w cedar rapids 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. |
2023-11-05 |
David Sickels |
davidasickels@gmail.com |
Cedar rapids |
Linn |
Iowa |
Chad Allen Taylor |
Steven Thomas Dunn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Allen Sickels |
davidasickels@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Chad Allen Taylor |
Steven Thomas Dunn |
Signed |
1958 |
2023-12-15 12:26 |
Anonymous (not verified) |
94.188.205.168 |
Big & Steinke Construction |
Limited Liability Company |
1737 B Avenue NE Cedar Rapids, Iowa 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-15 |
Jordan Bigbee |
bigandsteinkeconstruction@gmail.com |
Cedar Rapids |
Iowa |
United States |
Zachary Steinke |
Taylor Bigbee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Zachary Steinke |
bigandsteinkeconstruction@gmail.com |
Owner |
Cedar Rapids |
Iowa |
United States |
Jordan Bigbee |
Taylor Bigbee |
Signed |
1973 |
2024-01-02 17:05 |
Anonymous (not verified) |
94.188.207.227 |
Diego Puente |
Proprietorship |
1420 north st, apt#3 Perry Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-02 |
Diego Puente Martinez |
diegopuente0655@gmail.com |
Perry |
Dallas |
Iowa |
Jason Van Dyke |
Ashley Heffernen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jason Van Dyke |
jvandyke@thermalshop.com |
worker |
Cedar Rapids |
Iowa |
United States |
Jason Van Dyke |
Ashley Heffernen |
Signed |
1998 |
2024-01-25 16:18 |
Anonymous (not verified) |
94.188.205.168 |
Faith and Trust Soulutions LLC |
Limited Liability Company |
139 37th Street NE Suite # 2 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-25 |
Marie Moore |
faithandtrustsoulutionsllc@gmail.com |
Cedar Rapids |
Iowa |
United States |
Arthur Barbine |
Arthur Barbine |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Arthur Barbine |
faithandtrustsoulutionsllc@gmail.com |
Friend |
Cedar Rapids |
Iowa |
United States |
Arthur Barbine |
Arthur Barbine |
Signed |
1999 |
2024-01-25 16:57 |
Anonymous (not verified) |
94.188.205.177 |
Nicholas Schaff |
Limited Liability Company |
6934 rolling ridge ct sw cedar rapids Iowa 52404 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-25 |
Nicholas Schaff |
schaff.lawncare@gmail.com |
cedar rapids |
linn |
iowa |
Brian Zeller |
Cassie Schaff |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas schaff |
schaff.lawncare@gmail.com |
Same person |
cedar rapids |
iowa |
iowa |
Brian zeller |
cassie schaff |
Signed |
2002 |
2024-01-26 17:00 |
Anonymous (not verified) |
94.188.207.228 |
Legacy Group Consulting |
Limited Liability Company |
3721 Coppermill Rd NE, Cedar Rapids, IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-26 |
John A Scott |
legacygrpconsulting@gmail.com |
Cedar Rapids |
Linn |
IA |
Barbara Scott |
Robert Moore |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John A Scott |
legacygrpconsulting@gmail.com |
Owner |
Cedar Rapids |
Linn |
IA |
Barbara Scott |
Robert Moore |
Signed |
2057 |
2024-02-26 16:17 |
Anonymous (not verified) |
94.188.207.228 |
Pedro Salazar Trejo |
Proprietorship |
1116 18th Ave SW Cedar Rapids IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-26 |
Pedro Salazar Trejo |
pedrosalazart@icolud.com |
Cedar rapids |
Linn County |
IA |
Carlos Izaguirre |
Omar Trejo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Martiniano Germán Maldonado |
maldonadomartiniano675@gmail.com |
Employee |
Cedar rapids |
Linn County |
Iowa |
Carlos Izaguirre |
Omar Trejo |
Signed |
2087 |
2024-03-11 09:39 |
Anonymous (not verified) |
94.188.205.175 |
Shear Texture |
Limited Liability Company |
2000 Wiley Blvd SW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2024-03-11 |
Wendy Kiser |
kiser187@msn.com |
Cedar Rapids |
Linn |
Iowa |
Kim Erickson |
Shauna Whitaker |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Wendy Kiser |
kiser187@msn.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Kim Erickson |
Shauna Whitaker |
Signed |
2096 |
2024-03-14 14:53 |
Anonymous (not verified) |
94.188.205.168 |
Scott Allen |
Proprietorship |
2603 Bryant Blvd SW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-14 |
Scott Michael Allen |
allen.scottm@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Daniel Bryant Bliek |
Jennifer Lee Allen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Scott Michael Allen |
allen.scottm@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Daniel Bryant Bliek |
Jennifer Lee Allen |
Signed |
2121 |
2024-03-28 00:05 |
Anonymous (not verified) |
94.188.205.176 |
James bunting |
Limited Liability Company |
6213 ridgewood meadows LN 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. |
2024-03-28 |
James bunting |
jbflooringtile@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Codee Marie |
Matt reynolds |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James bunting |
jbflooringtile@gmail.com |
Myself |
Cedar Rapids |
Linn |
Iowa |
Codee Marie |
Matt reynolds |
Signed |
2146 |
2024-04-12 11:42 |
Anonymous (not verified) |
94.188.207.226 |
Ken McGraw |
Proprietorship |
162 Green St Center Point IA 52213 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-12 |
Ken Mcgraw |
kenmcgraw1974@gmail.com |
Center Point |
Linn |
Iowa |
Jenny Vaske |
Bob Nissen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Ashlock |
brian@tricounty-iowa.com |
General Manager |
Cedar Rapids |
Linn |
Iowa |
Bob Nissen |
Jenny Vaske |
Signed |
1046 |
2022-04-14 08:11 |
Anonymous (not verified) |
104.36.120.68 |
jet drywall |
Limited Liability Company |
5611 westminster DR #5 cedarfalls IA 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-14 |
murion jones |
jetdrywall.construction@gmail.com |
cedarfalls |
black hawk |
iowa |
murion parely jones |
murion jones |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
murion jones |
jetdrywal.construction@gmail.com |
owner |
cedarfalls |
black hawk |
iowa |
Murion Jones JR |
Eric Jones |
Signed |
1047 |
2022-04-14 08:11 |
Anonymous (not verified) |
104.36.120.68 |
jet drywall |
Limited Liability Company |
5611 westminster DR #5 cedarfalls IA 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-14 |
murion jones |
jetdrywall.construction@gmail.com |
cedarfalls |
black hawk |
iowa |
murion parely jones |
murion jones |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
murion jones |
jetdrywal.construction@gmail.com |
owner |
cedarfalls |
black hawk |
iowa |
Murion Jones JR |
Eric Jones |
Signed |
1243 |
2022-08-04 21:00 |
Anonymous (not verified) |
173.24.221.228 |
Foreman's Tile Creations |
Proprietorship |
1412 Franklin St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-04 |
Sole Proprietor |
fudog4man@gmail.com |
Center Point |
Linn |
IA |
Aaron Foreman |
Aaron Foreman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aaron Foreman |
fudog4man@gmail.com |
I am the Employer |
Center Point |
Linn |
IA |
Aaron Foreman |
Aaron Foreman |
Signed |
1371 |
2022-11-14 10:55 |
Anonymous (not verified) |
166.181.86.95 |
Dean Abramczak |
Proprietorship |
524 Nodaway Dr center Point Iowa 52213 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Dean Abramczak |
gabramczak@gmail.com |
Center Point |
IA |
United States |
Brenda Oconner |
Kenny McGraw |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dean Abramczak |
gabramczak@gmail.com |
I am the only employee I own the company |
Center Point |
IA |
United States |
Brenda Oconnner |
Kenny McGraw |
Signed |
1923 |
2023-11-27 11:21 |
Anonymous (not verified) |
94.188.207.230 |
Chilled LLC |
Limited Liability Company |
236 Meadow Breeze Ln Center Point IA 52213 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-27 |
Lindsy J Trotter |
Lindsy@chilledfreezermeals.com |
Center Point |
Linn |
Iowa |
Abbie Snakenberg |
Amanda Guttau |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lindsy Trotter |
Lindsy@chilledfreezermeals.com |
Owner |
Center Point |
Linn |
Iowa |
Abbie Snakenberg |
Amanda Guttau |
Signed |
1983 |
2024-01-11 13:02 |
Anonymous (not verified) |
94.188.205.168 |
r&k propety solutions |
Proprietorship |
po box 53 cedar rapids iowa 52406 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-11 |
roy rohwedder |
rohwedder.roy@yahoo.com |
Cedar Rapids |
linn |
ia |
Brian Ashlock |
tim vaske |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Ashlock |
brian@tricounty-iowa.com |
General Manager |
Center Point |
Benton |
ia |
Tim Vaske |
Roy Rohwedder |
Signed |
2094 |
2024-03-14 10:16 |
Anonymous (not verified) |
94.188.207.225 |
Timothy Deutmeyer |
Proprietorship |
4014 iowa rd Center Point IA 52213 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-14 |
Timothy Francis Deutmeyer |
timothydeutmeyer65@gmail.com |
Center Point |
Linn |
Iowa |
JAKE. Mcnurlaen |
Kevin Kinzebach |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy Francis Deutmeyer |
timothydeutmeyer65@gmail.com |
Owner |
CENTER POINT |
Linn |
Iowa |
Jake Mcnurlaen |
Kevin Kinzebach |
Signed |
38 |
2020-01-18 12:15 |
Anonymous (not verified) |
206.109.174.199 |
BJS Frenchies, LLC |
Limited Liability Company |
20081 Highway J 46 Centerville Iowa 52544 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-06 |
J. Jamie Tracy |
jamiespuppies@yahoo.com |
Centerville |
Appanoose |
Iowa |
Misty O'Hair |
Casey Leach |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bruce E Tracy |
jamiespuppies@yahoo.com |
Husband and Co Owner |
Centerville |
Appanoose |
Iowa |
Misty O'Hair |
Casey Leach |
Signed |
502 |
2021-05-04 12:56 |
Anonymous (not verified) |
75.89.78.95 |
HENNICK TREE SERVICE LLC |
Limited Liability Company |
1852 MAINE RIDGE ROAD, CENTRAL CITY, IA 52214 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-05-04 |
BRANDON ALAN HENNICK |
hennicktreeservice@gmail.com |
CENTRAL CITY |
LINN |
IOWA |
KATHY RUTH WOOD |
ROBBIE WILLIAM WILLIS |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Brandon Hennick |
hennicktreeservice@gmail.com |
OWNER |
CENTRAL CITY |
IA |
United States |
KATHY RUTH WOOD |
ROBBIE WILLIAM WILLIS |
Signed |
917 |
2022-02-16 09:48 |
Anonymous (not verified) |
167.142.86.212 |
Susan A Cunningham |
Proprietorship |
3409 Stone City Rd, Central City IA 52214 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Susan A Cunningham |
2oldrabbits@gmail.com |
Central City |
Linn |
Iowa |
Donna Zimmerman |
Norm Zimmerman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Susan A Cunningham |
2oldrabbits@gmail.com |
self |
Central City |
Linn |
Iowa |
Donna Zimmerman |
Norm Zimmerman |
Signed |
1217 |
2022-07-21 06:51 |
Anonymous (not verified) |
209.152.88.53 |
Bullard Accounting Services, LLC |
Limited Liability Company |
4519 Scouts View Dr, Central City, IA 52214 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-21 |
Michael Bullard |
mikeandkarenbullard@gmail.com |
CENTRAL CITY |
IA |
United States |
Karen Bullard |
Nicole Nassif |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Bullard |
mikeandkarenbullard@gmail.com |
President of Company |
CENTRAL CITY |
IA |
United States |
Karen Bullard |
Nicole Nassif |
Signed |
1538 |
2023-03-27 15:20 |
Anonymous (not verified) |
94.188.205.167 |
Luke Woods |
Limited Liability Company |
1513 Burnett Station Road Central City, IA 52214 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-27 |
Luke James Woods |
woodsmencontractingllc@gmail.com |
Central City |
Linn |
Iowa |
Keith John Woods |
Heath John Woods |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luke James Woods |
woodsmencontractingllc@gmail.com |
same person |
Central City |
Linn |
Iowa |
Keith John Woods |
Heath John Woods |
Signed |
1702 |
2023-06-22 22:57 |
Anonymous (not verified) |
94.188.207.230 |
A&M Consulting LLC |
Limited Liability Company |
1208 5th Ave, North Humboldt Iowa, 50548 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-22 |
maureen Waweru |
maureenrealtyaz@yahoo.com |
chandler |
AZ |
United States |
John Waweru |
Jessica Bellinger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
maureen Waweru |
maureenrealtyaz@yahoo.com |
Self |
chandler |
AZ |
United States |
John Waweru |
Jessica Bellinger |
Signed |
1213 |
2022-07-19 14:00 |
Anonymous (not verified) |
198.14.220.143 |
VLG Build & Remodle LLC |
Limited Liability Partnership |
45547 State HWY 14 Chariton, IA 50049 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-19 |
Vladimir Golosinskiy |
VLGCONSTRUCTION@YAHOO.COM |
Chariton |
IA |
United States |
Vladimir Golosinskiy |
Vladimir Golosinskiy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LILIA GOLOSINSKIY |
VLGCONSTRUCTION@YAHOO.COM |
Wife |
CHARITON |
Iowa |
United States |
LILIA GOLOSINSKIY |
LILIA GOLOSINSKIY |
Signed |