1633 |
2023-05-09 15:46 |
Anonymous (not verified) |
94.188.205.168 |
Unique Painting, LLC |
Partnership |
2500 E. 39Th Court |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Ricardo Rodriguez Perfecto |
uniquepainting00@gmail.com |
Des Moines |
USA |
IOWA |
Oseas Diaz |
Jorge Corona |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ricardo Rodriguez Perfecto |
uniquepainting00@gmail.com |
Vice president |
Des Moines |
USA |
IOWA |
Oseas Diaz |
Jorge Corona |
Signed |
1646 |
2023-05-15 13:13 |
Anonymous (not verified) |
94.188.207.224 |
Aspen leaf Painting |
Limited Liability Company |
3846 Lower Beaver 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. |
2023-05-15 |
Michael Patrick Vajda |
m.p.vajda@gmail.com |
Des Moines |
Polk |
IA |
Patrick Vajda |
Mike Vajda |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mike Vajda |
m.p.vajda@gmail.com |
Self |
Des Moines |
Polk |
IA |
Mike Vajda |
Michael Vajda |
Signed |
1691 |
2023-06-14 19:20 |
Anonymous (not verified) |
94.188.205.174 |
Amazing Painting LLC |
Limited Liability Company |
1301 Boyd Street, Des Moines, IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-14 |
Evan Michael Regenwether |
Evan@amazingpaintingia.com |
Des Moines |
Polk |
Iowa |
Austin Matthew Regenwether |
Abby Marie Regenwether |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Evan Michael Regenwether |
evan@amaingpaintingia.com |
Owner |
Des Moines |
Polk |
Iowa |
Austin Matthew Regenwether |
Abby Regenwether |
Signed |
1692 |
2023-06-15 15:20 |
Anonymous (not verified) |
94.188.207.228 |
Javier Rodriguez |
Proprietorship |
1512 18th St Des Moines, Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-14 |
Javier A Rodriguez |
R.Javier14@gmail.com |
Des Moines |
Polk |
Iowa |
Kelly Denger |
Debra Stratton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Javier A Rodriguez |
R.Javier14@gmail.com |
self |
Des Moines |
Polk |
Iowa |
Kelly Denger |
Debra Stratton |
Signed |
1707 |
2023-06-25 10:39 |
Anonymous (not verified) |
94.188.207.224 |
Michael D Ray |
Proprietorship |
4944 Holcomb Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-22 |
Michael D Ray Jr |
mdray01@msn.com |
Des Moines |
Polk |
Iowa |
Bonnie R Finken |
Isaiah O Washington |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael D Ray |
mdray01@msn.com |
Owner Proprietor |
Des Moines |
Polk |
Iowa |
Bonnie R Finken |
Isaiah O Washington |
Signed |
1724 |
2023-07-06 19:34 |
Anonymous (not verified) |
94.188.207.223 |
ALDO B. CANCINO HERNANDEZ |
Proprietorship |
2524 SHADOW CREEK LN, DES MOINES, IA 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-06 |
ALDO B. CANCINO HERNANDEZ |
aldo94.cansino@gmail.com |
DES MOINES |
USA |
IOWA |
JUAN M. MAYORGA |
OFELIA BUSTILLOS VALENZUELA |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
ALDO B. CANCINO HERNANDEZ |
aldo94.cancino@gmail.com |
SELF |
DES MOINES |
USA |
IOWA |
JUAN M. MAYORGA |
OFELIA BUSTILLOS VALENZUELA |
Signed |
1725 |
2023-07-07 13:37 |
Anonymous (not verified) |
94.188.205.167 |
Liana Fatino |
Limited Liability Company |
1930 se 14th des moines iowa 50321 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-07 |
Liana Fatino |
lfatino@yahoo.com |
des moines |
USA |
Iowa |
Liana Fatino |
Gary Fatino |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Liana Fatino |
lfatino@yahoo.com |
wife |
des moines |
USA |
iowa |
Liana Fatino |
Gary Fatino |
Signed |
1729 |
2023-07-09 15:33 |
Anonymous (not verified) |
94.188.207.223 |
Melvin A mineros |
Limited Liability Company |
6209 Windsor dr des moines IA 50312 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-09 |
Melvin A mineros |
minerosframing.llc@gmail.com |
Des moines |
Polk |
IA |
Orlando dominguez |
Isaac salazar |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jaime leiva |
jaime@boersmaninsurance.com |
Agent |
Des moines |
Polk |
IA |
Narciso hidalgo |
Balmore perez |
Signed |
1734 |
2023-07-11 08:25 |
Anonymous (not verified) |
94.188.207.226 |
LBN LLC |
Limited Liability Company |
1930 se 14th Des Moines Iowa 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-11 |
Liana Fatino |
lfatino@yahoo.com |
Des Moines |
Polk |
Iowa |
Liana Fatino |
Gary Fatino |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Liana Fatino |
lfatino@yahoo.com |
owner |
des moines |
polk |
Iowa |
Liana Fatino |
Gary Fatino |
Signed |
1735 |
2023-07-11 08:28 |
Anonymous (not verified) |
94.188.207.229 |
LBN LLC |
Limited Liability Company |
1930 se 14th Des Moines Iowa 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-11 |
Gary Fatino |
fatinomarketinggroup@yahoo.com |
Des Moines |
polk |
Iowa |
Liana Fatino |
Gary Fatino |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gary Fatino |
fatinomarketinggroup@yahoo.com |
owner |
des moines |
polk |
iowa |
liana fatino |
gary fatino |
Signed |
1736 |
2023-07-11 08:30 |
Anonymous (not verified) |
94.188.207.228 |
Scornos Waukee LLC |
Limited Liability Company |
286 w hickman rd waukee iowa 50263 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-11 |
Liana Fatino |
lfatino@yahoo.com |
des moines |
polk |
iowa |
Liana Fatino |
Gary Fatino |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Liana Fatino |
lfatino@yahoo.com |
owner |
des moines |
polk |
IOWA |
Liana Fatino |
Gary Fatino |
Signed |
1737 |
2023-07-11 08:32 |
Anonymous (not verified) |
94.188.207.223 |
Scornos waukee llc |
Limited Liability Company |
286 w hickman rd waukee iowa 50263 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-11 |
Gary Fatino |
fatinomarketinggroup@yahoo.com |
des moines |
polk |
iowa |
Liana Fatino |
Gary Fatino |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gary Fatino |
fatinomarketinggroup@yahoo.com |
owner |
des moines |
polk |
iowa |
Liana Fatino |
Gary Fatino |
Signed |
1738 |
2023-07-11 10:51 |
Anonymous (not verified) |
94.188.207.224 |
Augustin Santos |
Proprietorship |
109 Loomis Ave Des Moines, Iowa 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-05 |
Augustin Santos |
deb@piciowa.com |
Des Moines |
Polk |
Iowa |
Deb Stratton |
Kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Augustin Santos |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Deb Stratton |
Kelly Denger |
Signed |
1743 |
2023-07-13 10:24 |
Anonymous (not verified) |
94.188.207.225 |
Sindi Merida Alvarez MA Consttuction LLC |
Proprietorship |
2048 Lyon St DM, IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-24 |
Sindi Merida-Alvarez dba MA Construction LLC |
deb@piciowa.com |
Des Moines |
Polk |
IA |
Debra Stratton` |
kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sindi Merida Alvarez dba MA Construction LLC |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Debra Stratton |
Kelly Denger |
Signed |
1745 |
2023-07-13 16:20 |
Anonymous (not verified) |
94.188.205.174 |
Gaytan Framing LLC |
Limited Liability Company |
4745 NE 27th Ct |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-13 |
Jose Gaytan Ruiz |
jose1988.jg8@gmail.com |
Des Moines |
Polk |
Des Moines |
Erwin Quintanilla |
Misael Balleza |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Gaytan Ruiz |
jose1988.jg8@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Edwin Quintanilla |
Misael Balleza |
Signed |
1749 |
2023-07-17 10:52 |
Anonymous (not verified) |
94.188.205.175 |
Zenon Loreto |
Proprietorship |
1324 E 29th St Des Moines, IOwa 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-17 |
Zenon Loreto |
deb@piciowa.com |
Des Moines |
Polk |
Iowa |
Inspro in 2019 |
Inspro in 2019 |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Zenon Loreto |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Inspro in 2019 |
Inspro in 2019 |
Signed |
1750 |
2023-07-17 11:00 |
Anonymous (not verified) |
94.188.205.166 |
Mario Flores |
Proprietorship |
2101 E Virginia Ave. Apt 1 Des Moines, Iowa 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-22 |
Mario Zubia Flores |
deb@piciowa.com |
Des Moiines |
Polk |
Iowa |
Inspro employee 2022 |
Inspro employee 2022 |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mario Zubia Flores |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Inspro employee 2022 |
Inspro employee 2022 |
Signed |
1751 |
2023-07-17 11:00 |
Anonymous (not verified) |
94.188.205.166 |
Mario Flores |
Proprietorship |
2101 E Virginia Ave. Apt 1 Des Moines, Iowa 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-22 |
Mario Zubia Flores |
deb@piciowa.com |
Des Moiines |
Polk |
Iowa |
Inspro employee 2022 |
Inspro employee 2022 |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mario Zubia Flores |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Inspro employee 2022 |
Inspro employee 2022 |
Signed |
1753 |
2023-07-18 14:41 |
Anonymous (not verified) |
94.188.205.168 |
Cruz Lerma |
Proprietorship |
1439 17th Ct Des Moines, Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-18 |
Cruz Lerma |
deb@picowa.com |
Des Moines |
Polk |
Iowa |
Deb Stratton |
Kelly K Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cruz Lerma |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Deb Stratton |
Kelly K Denger |
Signed |
1768 |
2023-07-29 11:10 |
Anonymous (not verified) |
94.188.207.223 |
Makana Industries LLC |
Limited Liability Company |
1800 Grand Ave #352, West Des Moines, IA 50265 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-29 |
Matthew Akana |
mandiremod515@gmail.com |
West Des Moines |
Polk |
Iowa |
Catherine Sobrado |
James Fowler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rocket Lawyer Corporate Services LLC |
mandiremod515@gmail.com |
Registered agent |
Des Moines |
Polk |
Iowa |
Catherine Sobrado |
James Fowler |
Signed |
1775 |
2023-08-03 09:37 |
Anonymous (not verified) |
94.188.207.227 |
J j builder llc |
Limited Liability Company |
2307 richland dr des moines ia |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-28 |
José Cruz Jasso balleza |
jassoprimo03@icloud.com |
Des moines |
Polk |
Iowa |
Jaime Rodrigues |
Mario ramos |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Irving |
iibarra@centroinsurance.com |
Agent |
Des moines |
Polk |
Iowa |
Irving Ibarra |
Jaime Rodrigues |
Signed |
1778 |
2023-08-03 14:52 |
Anonymous (not verified) |
94.188.207.227 |
Melvin A mineros |
Limited Liability Company |
6209 Windsor dr des moines IA 50312 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2023-06-22 |
Melvin alexander mineros |
minerosframing.llc@gmail.com |
Des moines |
Polk |
IA |
Orlando dominguez |
Isaac salazar |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jaime leiva |
jaime@boersmaninsurance.com |
Agent |
Des moines |
Polk |
IA |
Narciso hidalgo |
Balmore perez |
Signed |
1784 |
2023-08-04 10:39 |
Anonymous (not verified) |
94.188.205.175 |
Danny Davis |
Limited Liability Company |
2733 Raccoon Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-04 |
Danny R Davis |
ddavis3243@yahoo.com |
Des Moines |
IA |
United States |
Michael Gatewood |
Brad Wheeler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
HD EXTERIORS LLC |
ddavis3243@yahoo.com |
Owner |
Des Moines |
IA |
United States |
Michael Gatewood |
Brad Wheeler |
Signed |
1786 |
2023-08-07 05:08 |
Anonymous (not verified) |
94.188.205.169 |
Ph Construction Limited Liability Company |
Limited Liability Company |
2643 Beaver Ave Suite 105 Des Moines Iowa 50310 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-07 |
Patricia Ann Hook |
patricia.diverseconstruction@gmail.com |
Des Moines |
United States |
United States |
Allen W Butts |
Kate Ridge |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Patricia Ann Hook |
patricia.diverseconstruction@gmail.com |
Self - Owner |
Des Moines |
United States |
Iowa |
Allen W Butts |
Kate Ridge |
Signed |
1798 |
2023-08-14 12:16 |
Anonymous (not verified) |
94.188.207.223 |
David Robles |
Proprietorship |
3912 E 23rd St Des Moines, Iowa 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-09 |
David Robles |
deb@piciowa.com |
Des Moines |
Polk |
Iowa |
Debra E Stratton |
Kelly K Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Robles |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Kelly K Denger |
Debra E Stratton |
Signed |
1807 |
2023-08-17 12:45 |
Anonymous (not verified) |
94.188.205.175 |
LONE STAR ROOFING, LLC |
Limited Liability Company |
4021 WINDSOR CT DES MOINES, IA 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-17 |
RAQUEL B DIAZ MENENDEZ |
LONE.STAR.ROOFING76@GMAIL.COM |
DES MOINES |
USA |
IOWA |
LILIANA SANCHEZ |
RENE ALEXANDER VELASCO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LONE STAR ROOFING, LLC |
LONE.STAR.ROOFING76@GMAIL.COM |
MEMBER OWNER |
DES MOINES |
USA |
IOWA |
LILIANA SANCHEZ |
RENE ALEXANDER VELASCO |
Signed |
1821 |
2023-08-29 10:11 |
Anonymous (not verified) |
94.188.205.169 |
Des Moines Smart Solutions LLC |
Limited Liability Company |
1329 56th St., Des Moines, IA 50311 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-29 |
Denzel Colocho |
alejandro_colocho@yahoo.com |
Des Moines |
Polk |
Iowa |
Steve Webb |
Austin Kelderman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Des Moines Smart Solutions LLC |
alejandro_colocho@yahoo.com |
Owner |
Des Moines |
Polk |
Iowa |
Steve Webb |
Austin Kelderman |
Signed |
1849 |
2023-09-19 14:57 |
Anonymous (not verified) |
94.188.207.228 |
Iowa painting solutions llc |
Limited Liability Company |
2500 pleasant st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-19 |
Patricia Davalos |
iowapaintingsolutionsllc@gmail.com |
Des Moines |
Polk |
Iowa |
Javier Rascon |
Angel Perez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Iowa painting solutions llc |
iowapaintingsolutionsllc@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Javier Rascon |
Angel Perez |
Signed |
1851 |
2023-09-22 12:36 |
Anonymous (not verified) |
94.188.207.229 |
MNM Construction |
Proprietorship |
3224 sw 12th place des moines iowa 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-22 |
craig allen mccormick |
craigmccormick.6363@gmail.com |
Des Moines |
Iowa |
Iowa |
Tara Murphy |
Kristie Hubbard |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
craig mccormick |
craigmccormick.6363@gmail.com |
self |
Des Moines |
Iowa |
Iowa |
Tara Murphy |
Kristie Hubbard |
Signed |
1859 |
2023-10-04 07:54 |
Anonymous (not verified) |
94.188.205.167 |
Pacheco Constructrion |
Limited Liability Company |
1614 Center Street, Des Moines IA 50314 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-04 |
Ulises Pacheco |
info@pachecoconstruction.com |
Des Moines |
Polk |
Iowa |
Melissa Gray |
Darci Rene Pacheco |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ulises Pacheco |
info@pachecoconstruction.com |
Self |
Des Moines |
Polk |
Iowa |
Melissa Gray |
Darci Rene Pacheco |
Signed |
1862 |
2023-10-05 14:30 |
Anonymous (not verified) |
94.188.207.225 |
J trinidad Garcia Ferrer |
Proprietorship |
3722 SE 14th St Apt 9 Des Moines, Iowa 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-01 |
J Trinidad Garcia Ferrer |
deb@piciowa.com |
Des Moines |
Polk |
Iowa |
Deb Stratton |
Martin Pinon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
J trinidad Garcia Ferrer |
deb@piciowa.com |
self |
Des Moines |
Polk |
IOwa |
Deb Stratton |
Martin Pinon |
Signed |
1865 |
2023-10-09 10:28 |
Anonymous (not verified) |
94.188.205.166 |
Lori Martinez |
Proprietorship |
6650 SE 5 TH STREET DES MOINES IA, 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-09 |
Lori Martinez |
azulbenavidez04@gmail.com |
Des Moines |
Polk |
Iowa |
R. Mitch Coluzzi |
Jennifer Lambert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lori Martinez |
azulbenavidez04@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
R. Mitch Coluzzi |
Jennifer Lambert |
Signed |
1870 |
2023-10-17 16:13 |
Anonymous (not verified) |
94.188.205.176 |
Diamond ridge |
Proprietorship |
1842 Glenwood cir Des Moines Iowa 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-17 |
Marianna Landeros |
cheri6876@yahoo.com |
Des moines |
Polk |
Iowa |
Marianna Landeros |
Cheri Martinez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marianna Landeros |
landerosmary@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Cheri Martinez |
Jessica Newton |
Signed |
1875 |
2023-10-23 11:34 |
Anonymous (not verified) |
94.188.205.176 |
Makers Blinds LLC |
Limited Liability Company |
3220 44Th St Des Moines, IA 50310 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Ryan Seiler |
makersblinds@gmail.com |
Des Moines |
Polk |
Iowa |
Jon Buller |
Terry Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Seiler |
makersblinds@gmail.com |
Manager |
Des Moines |
Polk |
Iowa |
Jon Buller |
Terry Miles |
Signed |
1881 |
2023-10-26 14:10 |
Anonymous (not verified) |
94.188.205.175 |
McAninch Painting LLC |
Limited Liability Company |
2422 Richmond Ave. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-26 |
Brian McAninch |
brian@allcoatfinishes.com |
Des Moines |
Polk |
Iowa |
Kane Fairman |
Brad Sandstoe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian McAninch |
brian@allcoatfinishes.com |
Self |
Des Moines |
polk |
Iowa |
Kane Fairman |
Brad Sandstoe |
Signed |
1891 |
2023-11-02 06:24 |
Anonymous (not verified) |
94.188.207.225 |
DOC Services |
Proprietorship |
3313 , E 7th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-01 |
Quentin Ferguson |
1quensy@gmail.com |
Des Moines |
Polk |
IA |
Dione Fergsuon |
Quensy Ferguson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Quentin Ferguson |
1quensy@gmail.com |
Self |
Des Moines |
Polk |
Ia |
Dione Ferguson |
Quensy Ferguson |
Signed |
1896 |
2023-11-03 14:23 |
Anonymous (not verified) |
94.188.207.225 |
Shane Adams |
Limited Liability Company |
3944 54th st Des Moines,IA 50310 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-03 |
Shane Steven Adams |
Shane6079@gmail.com |
Des Moines |
Polk |
Iowa |
Justin Mace |
Denice Sutton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shane Adams |
Shane6079@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Justin Mace |
Denice Sutton |
Signed |
1912 |
2023-11-16 08:40 |
Anonymous (not verified) |
94.188.205.175 |
JC LANDSCAPING & LAWN CARE |
Proprietorship |
4940 E. SHERIDAN AVE DES MOINES, IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-16 |
CLAUDIA TORO PINEDA |
CLAUDIAMEP@HOTMAIL.COM |
DES MOINES |
POLK |
IA |
BRENDA REEDY |
ADAM SMITH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
CLAUDIA TORO PINEDA |
CLAUDIAMEP@HOTMAIL.COM |
SELF |
DES MOINES |
POLK |
IA |
BRENDA REEDY |
ADAM SMITH |
Signed |
1917 |
2023-11-21 12:40 |
Anonymous (not verified) |
94.188.205.174 |
Ramos Painting LLC |
Limited Liability Company |
802 E COUNTY LINE RD #279, Des Moines, IA 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-01 |
Pedro Ramos |
gcort06@gmail.com |
Des Moines |
Polk |
Iowa |
Leonel Ramos |
Jose Ramos |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Pedro Ramos |
gcort06@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Leonel Ramos |
Jose Ramos |
Signed |
1919 |
2023-11-21 14:11 |
Anonymous (not verified) |
94.188.207.227 |
Refined Construction |
Limited Liability Company |
4148 Mattern ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-21 |
Dustin Martin |
dudtin.martin106@gmail.com |
Des Moines |
Polk |
IA |
Kelsey Baldinelli |
Brandi Martin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Martin |
dustin.martin106@gmail.com |
Sole officer |
Des Moines |
Polk |
IA |
Kelsey Baldinelli |
Brandi Martin |
Signed |
1922 |
2023-11-24 14:29 |
Anonymous (not verified) |
94.188.207.226 |
Tommie Prince private contractor |
Proprietorship |
2320 Farwell Road, Des Moines, IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-01 |
Tommie Prince |
amy@premierpayee.org |
Des Moines |
Polk |
Iowa |
Amy Meyer |
Morgan Meyer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tomme Prince private contractor |
amy@premierpayee.org |
Self |
Des Moines |
Polk |
Iowa |
Amy Meyer |
Morgan Meyer |
Signed |
1943 |
2023-12-06 16:34 |
Anonymous (not verified) |
94.188.207.230 |
Your Neighbors Pressure Washing LLC |
Limited Liability Company |
2059 Lyon St Des Moines Iowa 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-06 |
Alejandro Bacano Rodriguez |
alejandrobacanorodriguez@gmail.com |
Des Moines |
Polk |
Iowa |
Breny Rodriguez |
Gabriela Martinez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alejandro Bacano Rodriguez |
alejandrobacanorodriguez@gmail.com |
Myself |
Des Moines |
Polk |
Iowa |
Breny Rodriguez |
Gabriela Martinez |
Signed |
1944 |
2023-12-06 16:41 |
Anonymous (not verified) |
94.188.207.226 |
Sell Now Iowa |
Limited Liability Company |
5525 Meredith Dr Suite B Des Moines, Iowa 50310 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-06 |
Alejandro Bacano Rodriguez |
alejandrobacanorodriguez@gmail.com |
Des Moines |
Polk |
Iowa |
Breny Rodriguez |
Gabriela Martinez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sale Now Iowa |
team@sellnowiowa.com |
None |
Des Moines |
Polk |
Iowa |
Breny Rodriguez |
Gabriela Martinez |
Signed |
1945 |
2023-12-06 16:47 |
Anonymous (not verified) |
94.188.205.169 |
Sell Now Iowa |
Limited Liability Company |
5525 Meredith Drive Suite B Des Moines Iowa 50310 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-06 |
Alejandro Bacano Rodriguez |
alejandrobacanorodriguez@gmail.com |
Des Moines |
Polk |
Iowa |
Breny Rodriguez |
Gabriela Martinez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sell Now Iowa |
team@sellnowiowa.com |
None |
Des Moines |
Polk |
Iowa |
Breny Rodriguez |
Gabriela Martinez |
Signed |
1946 |
2023-12-06 16:51 |
Anonymous (not verified) |
94.188.205.168 |
Blue Sky Renovations Iowa LLC |
Limited Liability Company |
2059 Lyon St Des Moines Iowa 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-06 |
Alejandro Bacano Rodriguez |
alejandrobacanorodriguez@gmail.com |
Des Moines |
Polk |
Iowa |
Breny Rodriguez |
Gabriela Martinez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sell Now Iowa |
team@sellnowiowa.com |
None |
Des Moines |
Polk |
Iowa |
Breny Rodriguez |
Gabriela Martinez |
Signed |
1948 |
2023-12-11 10:36 |
Anonymous (not verified) |
94.188.207.224 |
Just Like New Details LLC |
Limited Liability Company |
4665 NE 7th St. Des Moines, IA 50313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-11 |
Trinity Schroeder |
trinity@justlikenewdetails.com |
Des Moines |
Polk |
Iowa |
Jayson Jones |
Nikki Wilks |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Trinity Schroeder |
trinity@justlikenewdetails.com |
Member |
Des Moines |
Polk |
Iowa |
Jayson Jones |
Nikki Wilks |
Signed |
1960 |
2023-12-16 11:58 |
Anonymous (not verified) |
94.188.207.227 |
Landeros Framing |
Proprietorship |
2418 E 37th Ct |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-16 |
Francisco Javier Landeros Garcia |
garcialanderosfranciscojavier@gmail.com |
Des Moines |
IA |
IA |
Mirna Ruby |
Jose Gaytan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Francisco Javier Landeros Garcia |
garcialanderosfranciscojavier@gmail.com |
owner |
Des Moines |
IA |
IA |
Mirna Ruby |
Jose Gaytan |
Signed |
1965 |
2023-12-22 10:23 |
Anonymous (not verified) |
94.188.207.229 |
Shawn Cooney |
Proprietorship |
4425 Ne 34th Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-22 |
Shawn Nelson Cooney |
shawncooney59@gmail.com |
Des Moines |
polk |
IA |
Marie Cooney |
Shawntel Cooney |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shawn Cooney |
shawncooney59@gmail.com |
Myself |
Des Moines |
polk |
IA |
Marie Cooney |
Shawntel Cooney |
Signed |
1969 |
2023-12-28 15:46 |
Anonymous (not verified) |
94.188.205.176 |
Beau Vander Sluis |
Proprietorship |
3000 Seneca Avenue |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-28 |
Beau Vander Sluis |
beauvsluis@gmail.com |
Des Moines |
Polk |
United States |
Braden Banning |
Andrew Behanish |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Beau Vander Sluis |
beauvsluis@gmail.com |
Same |
Des Moines |
Polk |
United States |
Braden Banning |
Andrew Behanish |
Signed |
1971 |
2023-12-29 19:27 |
Anonymous (not verified) |
94.188.207.223 |
Megan Thibodeau |
Proprietorship |
4301 Adams Ave, Des Moines, IA 50310 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-29 |
Megan E Thibodeau |
megancallan@hotmail.com |
Des Moines |
Iowa |
United States |
Travis Releford |
Courtney Releford |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Megan E Thibodeau |
megancallan@hotmail.com |
Self |
Des Moines |
Iowa |
United States |
Travis Releford |
Courtney Releford |
Signed |
1980 |
2024-01-10 11:32 |
Anonymous (not verified) |
94.188.207.224 |
Raudel Correa |
Proprietorship |
1924 23rd St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-02 |
Raudel Correa |
deb@piciowa.com |
Des Moines |
Polk |
Iowa |
Martin Pinon |
Debra Stratton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Raudel Correa |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Martin Pinon |
Debra Stratton |
Signed |
1981 |
2024-01-10 22:12 |
Anonymous (not verified) |
94.188.205.175 |
Level Up Renovations LLC |
Limited Liability Company |
648 31st Street, Des Moines, IA 50312 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-10 |
Luis Humberto Cazares Lopez |
leveluprenovationsia@outlook.com |
Des Moines |
Polk |
Iowa |
Gabriela Joanne Cazares |
Raquel Medina |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luis Humberto Cazares Lopez |
leveluprenovationsia@outlook.com |
Owner |
Des Moines |
Polk |
Iowa |
Gabriela Joanne Cazares |
Raquel Medina |
Signed |
1996 |
2024-01-24 10:30 |
Anonymous (not verified) |
94.188.207.224 |
E&p quality home remodeling llc |
Limited Liability Company |
2660 NE 44th ct desmoines IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-24 |
Pedro martinez |
pmsalas82@gmail.com |
Des Moines |
Polk |
Iowa |
Rogelio martinez |
Rigoberto martinez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Pedro Martinez |
pmsalas82@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Rogelio Martínez |
Rigoberto Martínez |
Signed |
2026 |
2024-02-07 08:32 |
Anonymous (not verified) |
94.188.205.169 |
Strong Fencing & Decking LLC |
Limited Liability Company |
343 59th Street Des Moines Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-07 |
Jacob James Strong |
strongfencingdecking@gmail.com |
Des Moines |
Polk |
Iowa |
Paige Crowley |
Jacob Waugh |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jacob Strong |
strongfencingdecking@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Paige Crowley |
Jacob Waugh |
Signed |
2038 |
2024-02-08 07:44 |
Anonymous (not verified) |
94.188.205.167 |
Travis Toney |
Limited Liability Company |
932 w12th street south newton ia 50208 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-08 |
Travis Duane Toney |
travistoney1984@gmail.com |
Newton |
United States |
IA |
Rick lee Toney |
Brenda Ann Toney |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Phil glazer |
kg_Info@capitallandscaping.com |
Contractor |
Des Moines |
United States |
IA |
Rick lee Toney |
Brenda Ann Toney |
Signed |
2052 |
2024-02-22 07:37 |
Anonymous (not verified) |
94.188.207.229 |
Noahs Ark Flooring |
Proprietorship |
6212 se 2nd st des moines iowa 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-22 |
Noah James Daggett |
daggettnoah365@gmail.com |
Des moines |
Polk |
United States |
Malichi Cerrato |
Austin tolson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Noah James Daggett |
daggettnoah365@gmail.com |
Self |
Des moines |
IA |
United States |
Malichi Cerrato |
Austin tolson |
Signed |
2064 |
2024-02-29 11:53 |
Anonymous (not verified) |
94.188.207.227 |
Quality Masonry LLC |
Limited Liability Company |
4121 14th st des moines ia 50313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-29 |
Wilian Nunez |
williamnunez77@gmail.com |
Des Moines |
IOWA |
United States |
Drake Rapaich |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wilian Nunez |
Williamnunez77@gmail.com |
Self |
Des Moines |
Polk |
IA |
Drake Rapaich |
Nathan Miller |
Signed |
2068 |
2024-03-01 09:53 |
Anonymous (not verified) |
94.188.207.226 |
A-1 Stone LLC |
Limited Liability Company |
4308 Boyd St Des Moines IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-01 |
Orlando Nunez |
nunezstone@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Perla Patricia Nunez |
nunezstone@gmail.com |
Employee |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2069 |
2024-03-01 09:55 |
Anonymous (not verified) |
94.188.207.226 |
A-1 Stone LLC |
Limited Liability Company |
4308 Boyd St Des Moines IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-01 |
Orlando Manuel Nunez Mejia |
orlando20025@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Perla Patricia Nunez |
nunezstone@gmail.com |
Employee |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2102 |
2024-03-18 10:56 |
Anonymous (not verified) |
94.188.207.228 |
NBJ Construction LLC |
Limited Liability Company |
2536 Capitol Ave Des Moines IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-18 |
Byron Jose Hernandez Nunez |
bjhernandez198807@gmail.com |
Des Moines |
Polk |
Iowa |
Nathan Miller |
Greg Beck |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
NBJ Construction LLC |
bjhernandez198807@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Nathan Miller |
Greg Beck |
Signed |
2103 |
2024-03-18 12:33 |
Anonymous (not verified) |
94.188.205.177 |
Scornos 1973 Inc |
Proprietorship |
8561 hickman rd urbandale iowa 50322 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-18 |
Liana Fatino |
lfatino@yahoo.com |
des moines |
POLK |
IOWA |
GARY FATINO |
LISA VACCO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
GARY FATINO |
lfatino@yahoo.com |
husband |
des moines |
polk |
iowa |
Gary Fatino |
Lisa Vacco |
Signed |
2104 |
2024-03-18 12:36 |
Anonymous (not verified) |
94.188.205.167 |
Scornoos 1973 INC |
Proprietorship |
8561 hickman rd urbandale iowa 50322 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-18 |
Gary Fatino |
lfatino@yahoo.com |
des moines |
Polk |
iowa |
Liana Fatino |
LISA VACCO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Liana Fatino |
lfatino@yahoo.com |
wife |
des moines |
polk |
iowa |
Liana Fatino |
Lisa vacco |
Signed |
2105 |
2024-03-18 12:45 |
Anonymous (not verified) |
94.188.205.169 |
Scornos Altoona LLC |
Proprietorship |
2437 adventureland dr altoona iowaa 50009 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-18 |
Liana Fatino |
lfatino@yahoo.com |
des moines |
POLK |
IOWA |
GARY FATINO |
LISA VACCO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
GARY FATINO |
lfatino@yahoo.com |
husband |
des moines |
polk |
iowa |
Gary Fatino |
Lisa Vacco |
Signed |
2106 |
2024-03-18 12:47 |
Anonymous (not verified) |
94.188.205.167 |
Scornos Altoona LLC |
Proprietorship |
2437 adventureland dr altoona iowaa 50009 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-18 |
Gary Fatino |
lfatino@yahoo.com |
des moines |
POLK |
IOWA |
Liana Fatino |
LISA VACCO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Liana Fatino |
lfatino@yahoo.com |
wife |
des moines |
polk |
iowa |
Liana Fatino |
Lisa Vacco |
Signed |
2107 |
2024-03-19 12:33 |
Anonymous (not verified) |
94.188.205.175 |
Elit Construction and Masonry LLC |
Partnership |
3309 Wright St. Des Moines, Ia 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-19 |
Manuel Mejia |
elitconstructionmasonryllc@gmail.com |
Des Moines |
Polk |
Iowa |
Heather Garber |
Kyle Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Manuel Mejia |
elitconstructionmasonryllc@gmail.com |
self |
Des Moines |
Polk |
Iowa |
Heather Garber |
Kyle Johnson |
Signed |
2109 |
2024-03-21 11:15 |
Anonymous (not verified) |
94.188.205.169 |
Panameno Stone |
Proprietorship |
3701 SE 18th Ct. Des Moines, IA 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-21 |
Domingo Panameno |
albertpana08@gmail.com |
Des Moines |
Polk |
Iowa |
Drakkar Rapaich |
Fabi Palomares |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Domingo Panameno |
albertpana08@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Drakkar Rapaich |
Fabi Palomares |
Signed |
2110 |
2024-03-21 13:29 |
Anonymous (not verified) |
94.188.205.174 |
Baroga Stone Masonry LLC |
Proprietorship |
1228 Loomis Ave Des Moines, IA 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-21 |
Bacilio Rodriguez |
barogastonemasonry@gmail.com |
Des Moines |
Polk |
Iowa |
Drakkar Rapaich |
Fabi Palomares |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bacilio Rodriguez |
barogastonemasonry@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Drakkar Rapaich |
Fabi Palomares |
Signed |
2118 |
2024-03-27 13:25 |
Anonymous (not verified) |
94.188.207.223 |
Zaragoza Home Solutions LLC |
Limited Liability Company |
1644 E Walnut St. Des Moines IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-27 |
Roberto C. Curiel |
zaragozahomesolutionsllc@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares Recendiz |
Francisco A Palomares Zepeda |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Roberto C Curiel |
zaragozahomesolutionsllc@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares Recendiz |
Francisco A Palomares Zepeda |
Signed |
2122 |
2024-03-28 10:15 |
Anonymous (not verified) |
94.188.205.169 |
Stone Villalobos LLC |
Limited Liability Company |
4231 Morton Ave Des Moines Iowa 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-28 |
Josue Villalobos |
villalobosjosue2016@gmail.com |
Des Moines |
Polk |
Iowa |
Edgar Palomares |
Fabiola Palomares Recendiz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josue Villalobos |
villalobosjosue2016@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Edgar Palomares |
Fabiola Palomares Recendiz |
Signed |
2124 |
2024-03-28 13:47 |
Anonymous (not verified) |
94.188.207.225 |
Gudiel Construction & Masonry LLC |
Limited Liability Company |
303 Lacona Ave Des Moines Iowa 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-28 |
Santiago Gudiel Lopez |
gudielsantiago972@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Santiago Gudiel Lpez |
gudielsantiago972@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2129 |
2024-04-01 14:16 |
Anonymous (not verified) |
94.188.207.227 |
Des Moines Construction LLC |
Limited Liability Company |
6615 SE 3rd St Des Moines IA 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-01 |
Rodrigo Valdes |
desmoinesconstructionllc@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rodrigo Valdes |
desmoinesconstructionllc@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2130 |
2024-04-02 09:11 |
Anonymous (not verified) |
94.188.207.229 |
Caliz Stone Services LLC |
Limited Liability Company |
1715 E 21st St, Des Moines IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-02 |
Marvin Lopez |
marvincaliz843@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marvin Lopez |
marvincaliz843@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2136 |
2024-04-04 16:08 |
Anonymous (not verified) |
94.188.205.169 |
Elite Construction & Masonry LLC |
Limited Liability Company |
3309 Wright St Des Moines IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-04 |
Manuel Mejia |
eliteconstructionmasonryllc@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Manuel Mejia |
eliteconstructionmasonryllc@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2156 |
2024-04-16 17:00 |
Anonymous (not verified) |
94.188.205.166 |
BONILLA STONE LLC |
Limited Liability Company |
3201 COLUMBIA ST DES MOINES, IA 50313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-16 |
JAIRO JAVIER BONILLA SERRANO |
jairobonilla509@gmail.com |
DES MOINES |
POLK |
IOWA |
ROCIO REYES |
JOSE HERNANDEZ |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JAIRO JAVIER BONILLA SERRANO |
jairobonilla509@gmail.com |
SAME |
DES MOINES |
POLK |
IOWA |
ROCIO REYES |
JOSE HERNANDEZ |
Signed |
2162 |
2024-04-18 19:25 |
Anonymous (not verified) |
94.188.205.177 |
Escobar Enterprises, LLC |
Limited Liability Company |
125 East Broad Street, Des Moines, Iowa 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-18 |
Jesse Escobar |
jesse@escobar-enterprises.com |
Des Moines |
Polk |
Iowa |
Rene Mauricio Martinez |
Jessa Caitlin Marfal |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jesse Escobar |
jesse@escobar-enterprises.com |
owner |
Des Moines |
Polk |
Iowa |
Rene Mauricio Martinez |
Jessa Caitlin Marfal |
Signed |
2187 |
2024-04-29 08:30 |
Anonymous (not verified) |
94.188.207.226 |
Fran Stonework LLC |
Limited Liability Company |
1222 E Seneca Ave Apt 7, Des Moines, IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-29 |
Francisco Rodriguez Rios |
panchito941@icloud.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Francisco Rodriguez Rios |
panchito941@icloud.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2194 |
2024-04-30 14:57 |
Anonymous (not verified) |
94.188.207.223 |
Juan Raymundo Hernandez |
Proprietorship |
3317 Scott Ave Des Moines, Iowa 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-25 |
Juan Raymundo Hernandez |
deb@piciowa.com |
Des Moines |
Poik |
Iowa |
Kelly Denger |
Debra Stratton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Juan Raymundo Hernandez |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Kelly Denger |
Debra Stratton |
Signed |
2196 |
2024-05-01 09:18 |
Anonymous (not verified) |
94.188.207.230 |
Penaloza Stone LLC |
Limited Liability Company |
1530 8th St Des Moines IA 50314 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-01 |
Javier Marcial Penaloza |
javiermarcial.jmp@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Javier Marcial Penaloza |
javiermarcial.jmp@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2197 |
2024-05-02 09:30 |
Anonymous (not verified) |
94.188.207.229 |
Melvin Osorio |
Proprietorship |
3848 E 14th St Trlr 78, Des Moines IA 50313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-02 |
Melvin Osorio |
matamorosana56@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melvin Osorio |
matamorosana56@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2198 |
2024-05-02 11:26 |
Anonymous (not verified) |
94.188.207.224 |
Sierra Stone LLC |
Limited Liability Company |
2504 E 37th St Des Moines IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-02 |
Daniel Nunez |
danieln2024@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Nunez |
danieln2024@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2200 |
2024-05-06 08:46 |
Anonymous (not verified) |
94.188.207.226 |
Dominguez Construction LLC |
Limited Liability Company |
1680 East Emma Des Moines, IA 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-05 |
Ramon Dominguez |
3memincolina@gmail.com |
Des Moines |
Polk |
Iowa |
Nathan Miller |
Stacey Lazear |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ramon Dominquez |
3memincolina@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Nathan Miller |
Stacey Lazear |
Signed |
2217 |
2024-05-09 14:28 |
Anonymous (not verified) |
94.188.207.224 |
Emmanual A Sanchez Chavez |
Proprietorship |
7301 Fleur Dr, Lot 10, Des Moines, IA 50325 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-09 |
Emmanuel A Sanchez Chaves |
alexsanchw3@gmail.com |
Des Moines |
Polk |
Iowa |
Jesus Garcia |
Fabion Dalgato |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Emmanuel A Sanchez Chavez |
alexsanchw3@gmail.com |
Person |
Des Moines |
Polk |
Iowa |
Jesus Garcia |
Fabion Dalgato |
Signed |
2092 |
2024-03-13 12:55 |
Anonymous (not verified) |
94.188.205.175 |
Banker's Lock and Safe |
Proprietorship |
1914 Porter Ave Des Moines Iowa 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-13 |
Jeff Losee |
bankerslockandsafe@yahoo.com |
Des Moines |
Polk |
IA |
Jennifer D Losee |
Kendra D Losee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeff Losee |
bankerslockandsafe@yahoo.com |
Owner |
Des Moines Iowa |
Polk |
IA |
Jennifer D Losee |
Kendra D Losee |
Signed |
245 |
2020-08-25 15:20 |
Anonymous (not verified) |
107.77.207.111 |
J&R cleaning co LLC |
Limited Liability Company |
14300 Holcomb ave #210 urbandale ia. 50323 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-25 |
José A salas romero |
chinito80sr@hotmail.com |
Desmoines |
Polk |
Iowa |
Ana López |
Jesus gonzales |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
José romero |
chinito80sr@hotmail.com |
Owner |
Desmoines |
Polk |
Iowa |
Ana lopez |
Jesus Gonzales |
Signed |
433 |
2021-03-12 20:47 |
Anonymous (not verified) |
173.28.1.65 |
HomeTeam painting llc |
Limited Liability Company |
3810 Amherst Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-12 |
Johnny ollin |
johnnyollin@gmail.com |
DesMoines |
Polk |
IOWA |
David Carney |
Chad Winslow |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Johnny ollin |
johnnyollin@gmail.com |
Myself |
DesMoines |
Polk |
IOWA |
David Carney |
Chad Winslow |
Signed |
777 |
2021-12-04 10:20 |
Anonymous (not verified) |
107.77.161.58 |
Martinez Painting |
Proprietorship |
3219 bowdoin st desmoines ia 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-04 |
Martinez Manuel |
Manuelitogladis29@gmail.com |
Desmoines |
Polk |
Iowa |
Yasco adilovic |
Samir radinovick |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Martinez Manuel |
Manuelitogladis29@gmail.com |
Owner |
Desmoines |
Polk |
Iowa |
Yasco adilovic |
Samir radinovic |
Signed |
1512 |
2023-03-10 09:44 |
Anonymous (not verified) |
94.188.205.169 |
eliseo isai |
Proprietorship |
5301 SE 24th St Des Moines, IA 50320 United States |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-08 |
eliseo isai carranza perez |
Misaelballeza40@gmail.com |
desmoines |
polk |
iowa |
Julio Nolvela |
giovanni nolvela |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
eliseo isai carranza perez |
Misaelballeza40@gmail.com |
self |
desmoines |
polk |
iowa |
Julio Nolvela |
giovanni nolvela |
Signed |
1530 |
2023-03-23 16:14 |
Anonymous (not verified) |
94.188.205.166 |
Los Cousins gutters |
Limited Liability Company |
901 sw 62nd st des moines ia 50312 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-23 |
Freddy Morales |
1981ayoria@gmail.com |
Des Moines Ia |
Polk |
Iowa |
Denni bazan |
Dionicio morales |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Freddy Morales |
1981ayoria@gmail.com |
1981ayoria@gmail.com |
Desmoines |
Polk |
Ia |
Dennis Bazan |
Dionicio Morales |
Signed |
1603 |
2023-04-25 20:42 |
Anonymous (not verified) |
94.188.205.174 |
Nursepro Staffing Agency |
Limited Liability Company |
8450 Hickman Rd suite A2 Clive iowa 50325 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2023-04-25 |
Teresiah muchemi |
nurseproagency@gmail.com |
desmoines |
polk |
iowa |
Teresiah Muchemi |
John Waweru |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Teresiah Muchemi |
nurseproagency@gmail.com |
Owner |
desmoines |
Polk |
iowa |
Teresiah Muchemi |
John Waweru |
Signed |
323 |
2020-11-19 10:55 |
Anonymous (not verified) |
174.192.67.61 |
Connor trucking |
Proprietorship |
2791 270th st Dewitt 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. |
2020-11-19 |
Richard Todd Connor |
connortrucking@hotmail.com |
Dewitt |
Clinton |
Iowa |
Michelle Connor |
Josh connor |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Richard Todd Connor |
connortruckin@hotmail.com |
Self |
Dewitt |
Clinton |
Iowa |
Michelle Connor |
Josh Connor |
Signed |
460 |
2021-04-05 15:24 |
Anonymous (not verified) |
173.20.169.155 |
Tim Stiles |
Proprietorship |
726 Grant St PO box 217 Dexter Iowa 50070 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-04 |
Tim Stiles |
timcolleenstiles@gmail.com |
Dexter |
Dallas |
Iowa |
Karen Penton |
ERIC TIERNAN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tim Stiles |
timcolleenstiles@gmail.com |
Same Tim Stiles |
Dexter |
Dallas |
Iowa |
Karen Penton |
Eric Tiernan |
Signed |
1672 |
2023-06-01 15:16 |
Anonymous (not verified) |
94.188.207.224 |
Raudel Correa Correa |
Proprietorship |
1924 23rd St Des Moines, IOwa 50313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-01 |
Raudel Correa Correa |
correaraudel6@gmail.com |
Des Moines |
Polk |
Iowa |
Debra Stratton |
Kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Raudel Correa Correa |
correaraudel6@gmail.com |
self |
DM |
Polk |
IA |
Den Stratton |
Kelly Denger |
Signed |
1491 |
2023-03-03 11:24 |
Anonymous (not verified) |
94.188.207.224 |
Ray gist |
Proprietorship |
4330 nw 9th st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-03 |
Raymond Rex Gist |
rrgist8@yahoo.com |
Dsm |
Polk |
Ia |
Amber Gist |
Victor Brawdy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Raymond Rex Gist |
rrgist8@yahoo.com |
Same person |
Dsm |
Polk |
Ia |
Amber Gist |
Victor Brawdy |
Signed |
14 |
2019-12-30 17:22 |
Anonymous (not verified) |
173.20.51.69 |
Rotten Love LLC |
Limited Liability Company |
1101 Valentine Drive, Dubuque Iowa 52003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-01-01 |
john rettenmeier |
jrettenmeier@gmail.com |
dubuque |
Dubuque |
iowa |
Carolyn Schmid |
Joe Rettenmeier |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Carolyn Schmid |
jrettenmeier@gmail.com |
owner |
Dubuque |
Dubuque |
iowa |
John Rettenmeier |
John Rettenmeier |
Signed |
30 |
2020-01-07 08:34 |
Anonymous (not verified) |
199.10.5.7 |
Data Information Management LLC |
Limited Liability Company |
703 Bluff St Dubuque IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-07 |
Stephen M Schauff |
steve@caricomm.com |
Dubuque |
Iowa |
IA |
Janet L Schauff |
Morris P Schauff |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christopher R Broessel |
chris@caricomm.com |
Partner |
Dubuque |
Iowa |
IA |
Janet L Schauff |
Morris P schauff |
Signed |
130 |
2020-04-27 10:36 |
Anonymous (not verified) |
66.188.136.150 |
David Roberts |
Proprietorship |
2600 Butterfield, PO Box 3251 Dubuque, IA 52004 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-24 |
David Roberts |
buman6578@gmail.com |
Dubuque |
Dubuque |
IA |
Russell Masartis |
Angie Olds |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Roberts |
kschumacher@tricorinsurance.com |
Owner Operator is Employer |
Dubuque |
Dubuque |
IA |
Russell Masartis |
Angie Olds |
Signed |
184 |
2020-06-12 10:38 |
Anonymous (not verified) |
174.243.112.246 |
brian kass |
Proprietorship |
15064 kass road |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-11 |
brian kass |
kass5kass@hotmail.com |
dubuque |
Iowa |
Iowa |
kelly kass |
jenny McIntyre |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
brian kass |
kass5kass@hotmail.com |
self |
dubuque |
Iowa |
iowa |
Kelly Kass |
Jenny McIntyre |
Signed |
244 |
2020-08-25 13:32 |
Anonymous (not verified) |
97.64.194.122 |
Soren Henriksen |
Proprietorship |
2165 Roosevelt St., Dubuque, IA 52001 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-20 |
Soren Henriksen |
kschumacher@tricorinsurance.com |
Dubuque |
Dubuque |
IA |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Soren Henriksen |
kschumacher@tricorinsurance.com |
Same |
Dubuque |
Dubuque |
IA |
Russell Masartis |
Nancy Wortley |
Signed |
285 |
2020-10-21 16:24 |
Anonymous (not verified) |
66.188.136.150 |
Roger Cole |
Proprietorship |
30 Devon Dr. Dubuque, IA 52001 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-21 |
Roger cole |
kschumacher@tricorinsurance.com |
Dubuque |
Dubuque |
IA |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Roger Cole |
kschumacher@tricorinsurance.com |
Same |
Dubuque |
Dubuque |
IA |
Russell Masartis |
Nancy Wortley |
Signed |
402 |
2021-02-15 16:33 |
Anonymous (not verified) |
66.188.136.150 |
K.C. Ansel |
Proprietorship |
101 Cherokee Dr. Dubuque, IA 52003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-15 |
K.C. Ansel |
kschumacher@tricorinsurance.com |
Dubuque |
Dubuque |
IA |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
K.C. Ansel |
kschumacher@tricorinsurance.com |
Same |
Dubuque |
Dubuque |
IA |
Russell Masartis |
Shuree Behr |
Signed |