443 |
2021-03-22 13:22 |
Anonymous (not verified) |
167.127.218.244 |
Romero Carpentry |
Proprietorship |
2060 King Ave, Apt 19, 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. |
2021-03-22 |
Jose Wilber Romero Batres |
Josew.batres@icloud.com |
Des moines |
Polk |
United States |
Gabriela Cecibel Chicas |
David Antonio Barrera Serrano |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Wilber Romero Batres |
Josew.batres@icloud.com |
Self |
Des Moines |
Polk |
Iowa |
Gabriela Cecibel Chicas |
David Antonio Barrera Serrano |
Signed |
1209 |
2022-07-17 16:41 |
Anonymous (not verified) |
166.181.86.161 |
JustbelieveCreationsllc |
Limited Liability Company |
104 East Chestnut 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. |
2022-07-17 |
Joshua Riera-Gomez |
josh.gomez.com@gmail.com |
Garnavillo |
IA |
United States |
Eric Jarman |
Jean brandt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua Riera-Gomez |
josh.gomez.com@gmail.com |
Myself |
Garnavillo |
IA |
United States |
Eric jarman |
Jean brandt |
Signed |
1200 |
2022-07-11 19:24 |
Anonymous (not verified) |
208.126.69.118 |
CMG Safety |
Limited Liability Company |
325 1st st. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-11 |
Chace Michael Garner |
chgarner18@gmail.com |
Truro |
Madison |
Iowa |
Josh Tomkins |
Kirsten Schirm |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Tompkins |
josh.thomkins@307safety.com |
Contractor |
Gillette |
Cambell |
Wyoming |
Chace Garner |
Kirsten Schirm |
Signed |
40 |
2020-01-19 13:20 |
Anonymous (not verified) |
167.142.82.171 |
Arganbright Land Improvement LLC |
Limited Liability Company |
2440 Redwood Ave. Guthrie Center, IA 50115 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-19 |
Josh Arganbright |
josh@arganbrightlandimp.com |
Guthrie Center |
Guthrie |
IA |
Kim Bauer |
Tom Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Arganbright |
josh@arganbrightlandimp.com |
self |
Guthrie Center |
Guthrie |
IA |
Kim Bauer |
Tom Smith |
Signed |
547 |
2021-06-24 08:05 |
Anonymous (not verified) |
97.125.169.60 |
Tenant Improvement Services, LLC |
Limited Liability Company |
3011 Justin Drive, Urbandale, IA 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. |
2021-06-24 |
Josh Chiles |
josh@tenantimprovementsiowa.com |
Des Moines |
Polk |
Iowa |
John Martin |
Johnny Holman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Chiles |
josh@tenantimprovementsiowa.com |
Member |
Des Moines |
Polk |
Iowa |
John Martin |
Johnny Holman |
Signed |
766 |
2021-11-22 16:19 |
Anonymous (not verified) |
63.229.189.35 |
Tribal Tile, LLC |
Limited Liability Company |
1402 Ithaca Ave, Spirit Lake, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-22 |
Josh Loerzel |
joshloerzel@gmail.com |
Spirit Lake |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Loerzel |
joshloerzel@gmail.com |
Self |
SPIRIT LAKE |
Dickinson |
IA |
Abigail Miles |
Alex Miles |
Signed |
1759 |
2023-07-26 07:09 |
Anonymous (not verified) |
94.188.207.225 |
Lima Charlie LLC |
Limited Liability Company |
56066 257th Street, Glenwood, IA 51534 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-26 |
Larry Joshua Homan |
Joshua@Lima-Charlie.biz |
Flatonia |
TX |
United States |
Leisha Kolb |
Troy Kolb |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Larry Joshua Homan |
Joshua@lima-charlie.biz |
Owner |
Flatonia |
Texas |
United States |
Leisha Kolb |
Troy Kolb |
Signed |
1008 |
2022-03-25 15:15 |
Anonymous (not verified) |
174.192.130.230 |
Hill's Rehab &Landscape L.L.C |
Limited Liability Company |
3717 15th ave Moline Illinois 61365 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-25 |
Joshua hill |
joshuajameshill79@gmail.com |
Moline |
Rock Island |
Illinois |
Lindsay erin Hill |
NICOLE ann lear |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua james hill |
joshuajameshill79@gmail.com |
President |
Moline |
Rock Island |
Illinois |
Lindsay Erin Hill |
NIcole ann lear |
Signed |
1347 |
2022-10-26 14:42 |
Anonymous (not verified) |
173.21.223.66 |
Mid American Roofing |
Limited Liability Company |
811 8th St Kalona IA 52247 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-26 |
Josiah Hoyt |
midamericanroofing@gmail.com |
KALONA |
IA |
United States |
Jensen Ropp |
Randy Ropp |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josiah Hoyt |
josiahhoyt@gmail.com |
Owner |
KALONA |
IA |
United States |
Jensen Ropp |
Randy Ropp |
Signed |
1814 |
2023-08-23 13:57 |
Anonymous (not verified) |
94.188.207.229 |
Exclusive Solutions LLC dba Jovan Guerrero |
Limited Liability Company |
2887 Jaden Lane Norwalk, Iowa 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-10 |
Jovan guerrero dba Exclusive Solutions LLC |
deb@piciowa.com |
Norwalk |
Polk |
Ia |
Debra Stratton |
Kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jovan Guerrero dba Exclusive SOlutions LLC |
jovanguerrero29@gmail.com |
self |
Norwalk |
Poik |
Iowa |
Debra Stratton |
Kelly Denger |
Signed |
1815 |
2023-08-23 14:16 |
Anonymous (not verified) |
94.188.207.228 |
JP Distribution, LLC |
Limited Liability Company |
3738 Pine Rdg NE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-23 |
Jared Prelle |
jpdist2014@gmail.com |
North Liberty |
IA |
United States |
Linda Stien |
Dawn Franck |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jared Prelle |
jpdist2014@gmail.com |
Owner |
North Liberty |
Johnson |
IA |
Linda Stien |
Dawn Franck |
Signed |
1071 |
2022-04-26 15:31 |
Anonymous (not verified) |
63.152.69.47 |
Black squirrel siding llc |
Limited Liability Company |
1512 n 1st Ave apt c203s coralville,ia52241 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-26 |
Jeremiah Petsche |
jpetsche44@gmail.com |
Coralville |
Johnson |
Iowa |
Jessica schimf |
Karl schimf |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeremiah petsche |
jpetsche44@gmail.com |
Myself |
Coralville |
Johnson |
Iowa |
Jessica schimf |
Karl schimf |
Signed |
305 |
2020-11-02 08:40 |
Anonymous (not verified) |
204.124.192.31 |
JPS Framing |
Proprietorship |
102 WALL 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. |
2020-11-02 |
JACKELYN SANCHEZ |
JPSFRAMING629@GMAIL.COM |
DES MOINES |
POLK |
IOWA |
ROGELIO SANCHEZ |
DOMINIQUE SANCHEZ |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JUAN SERRANO |
JPSFRAMING629@GMAIL.COM |
EMPLOYER |
DES MOINES |
POLK |
IOWA |
ROGELIO SANCHEZ |
DOMINIQUE SANCHEZ |
Signed |
1774 |
2023-08-03 08:40 |
Anonymous (not verified) |
94.188.205.168 |
J P Trucking, Inc. |
Proprietorship |
8768 White Tail Lane, 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. |
2021-08-03 |
Jamison Noel |
jptrucking.jamison@gmail.com |
Dubuque |
DBQ |
Iowa |
Lindsay Noel |
Andy Kemp |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jamison Noel |
jptrucking.jamison@gmail.com |
Owner |
Dubuque |
Dubuque |
Iowa |
Lindsay Noel |
Andy Kemp |
Signed |
1192 |
2022-07-07 21:15 |
Anonymous (not verified) |
174.242.226.74 |
Quelland Flooring |
Limited Liability Company |
P.O. Box 5, Van Meter, IA, 50261 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-07 |
Jared Tyler Quelland |
Jquelland@gmail.com |
Van Meter |
IA |
United States |
Denise Walters |
Madison Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jared Tyler Quelland |
Jquelland@gmail.com |
Self |
Van Meter |
IA |
United States |
Denise Walters |
Madison Mileer |
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 |
950 |
2022-03-04 19:58 |
Anonymous (not verified) |
173.26.94.212 |
JRH Services |
Limited Liability Company |
525 Third St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-04 |
Joshua Blakeslee |
jrhservicesiowa@outlook.com |
Evansdale |
Blackhawk |
IA |
Nicole Blakeslee |
Lois Riggleman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua Blakeslee |
jrhservicesiowa@outlook.com |
Owner |
Evansdale |
Blackhawk |
IA |
Nicole Blakeslee |
Lois Riggleman |
Signed |
1576 |
2023-04-17 08:32 |
Anonymous (not verified) |
94.188.205.167 |
Reece Wilson |
Limited Liability Company |
1431 Starbeck Circle |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-14 |
Reece J Wilson |
rjwilson030@gmail.com |
Cedar Falls |
Blackhawk |
Iowa |
Kendall Cotant |
Darryl Mason |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Richter |
jrichter@beecherlaw.com |
Business |
Waterloo |
Blackhawk |
Iowa |
Kendall Cotant |
Jared Hottle |
Signed |
302 |
2020-10-31 13:04 |
Anonymous (not verified) |
173.17.230.149 |
Absolute Construction |
Partnership |
3720 Patricia Drive, 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. |
2020-10-31 |
Joe Simpson |
jrsimpson27@gmail.com |
Urbandale |
Polk |
Iowa |
Alex Vanderbeek |
James Nelson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joe Simpson |
jrsimpson27@gmail.com |
self |
Urbandale |
Polk |
Iowa |
Alex Vanderbeek |
James Nelson |
Signed |
1053 |
2022-04-14 21:08 |
Anonymous (not verified) |
50.83.192.136 |
John E Snyder JR |
Proprietorship |
1677 PACIFIC ST, MURRAY, IA 50174 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-14 |
John Snyder JR |
jrsweldingia@gmail.com |
MURRAY |
Clarke |
Iowa |
Shelly Goslar |
Dorene Short |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Snyder JR |
jrsweldingia@gmail.com |
Selg |
MURRAY |
Clarke |
Iowa |
Shelly Goslar |
Dorene Short |
Signed |
1486 |
2023-02-26 17:53 |
Anonymous (not verified) |
94.188.205.177 |
TURNER LAWN CARE |
Limited Liability Company |
16493 185th 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. |
2023-02-27 |
JEFF TURNER |
jscturner2626@gmail.com |
MILO |
IA |
United States |
Tim Borrall |
BONNIE BORRALL |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SHARON RENEE TURNER |
jscturner2626@gmail.com |
wife |
MILO |
IA |
United States |
Tim Borrall |
BONNIE BORRALL |
Signed |
94 |
2020-03-18 13:18 |
Anonymous (not verified) |
174.243.114.80 |
Sogard Excavating |
Limited Liability Company |
2374 380th St, Jewell, IA 50130 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-18 |
Jon A Sogard |
jsogard22@gmail.com |
Jewell |
Hamilton |
IA |
Fallon Sogard |
Julee Lund |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sogard Excavating LLC |
jsogard22@gmail.com |
owner |
Jewell |
Hamilton |
IA |
Fallon Sogard |
Julee Lund |
Signed |
1839 |
2023-09-12 11:22 |
Anonymous (not verified) |
94.188.205.167 |
J.S. Reeves Consulting LLC |
Limited Liability Company |
1610 1st Ave, Perry, IA 50220 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-12 |
joni Sue Reeves |
jonisreeves@att.net |
Perry |
IA |
United States |
Maggie Rhodes |
Barb Butler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joni Sue Reeves |
jsreeves67@gmail.com |
Same |
Perry |
IA |
United States |
Maggie Rhodes |
Barb Butler |
Signed |
2101 |
2024-03-18 09:21 |
Anonymous (not verified) |
94.188.205.166 |
Jason Tindle |
Proprietorship |
4103 1st 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. |
2024-03-18 |
Jason Tindle |
jtconstruction93@yahoo.com |
DES MOINES |
IOWA |
United States |
Zach Miller |
Nick Soma |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jason Tindle |
jtconstruction93@yahoo.com |
Myself |
Same |
Same |
Same |
Same |
Same |
Signed |
437 |
2021-03-16 18:31 |
Anonymous (not verified) |
38.121.121.16 |
Thompsen Irrigation |
Proprietorship |
16086 Missouri Ave Crescent IA 51526 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-17 |
James R Thompsen |
jthom76285@aol.com |
Crescent |
Pottawattamie |
Iowa |
Mike Harmon |
Ilene Harmon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James R Thompsen |
jthom76285@aol.com |
self |
Crescent |
Pottawattamie |
Iowa |
Mike Harmon |
Ilene Harmon |
Signed |
582 |
2021-07-22 15:14 |
Anonymous (not verified) |
173.24.111.218 |
Joseph Davis |
Proprietorship |
7257 Valley Dr, bettendorf ia 52722 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-22 |
Joseph Davis |
jtigerd@live.com |
Bettendorf |
Scott |
IA |
Jacob nagel |
Nick brewer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joseph Davis |
jtigerd@live.com |
Agent |
Bettendorf |
IA |
IA |
Jacob nagel |
Nick brewer |
Signed |
1194 |
2022-07-08 13:12 |
Anonymous (not verified) |
174.45.15.103 |
307 Safety LLC |
Limited Liability Company |
9 Trinidad CT Gillette, WY 82716 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-08 |
Joshua Peter Tompkins |
JTompkins@307Safety.com |
Gillette |
Campbell |
Wyoming |
Paul Prather |
Jason Praus |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua Peter Tompkins |
JTompkins@307Safety.com |
Owner |
Gillette |
Campbell |
Wyoming |
Paul Prather |
Jason Praus |
Signed |
1082 |
2022-04-29 12:28 |
Anonymous (not verified) |
75.162.101.109 |
Jodi Trewet |
Proprietorship |
11920 NW 114th Ln Granger, IA 50109 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-29 |
Jodi Trewet |
jtrewet@yahoo.com |
Granger |
IA |
United States |
Mark Trewet |
Tyler Trewet |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jodi Trewet |
jtrewet@yahoo.com |
Same |
Granger |
Polk |
IA |
Mark Trewet |
Tyler Trewet |
Signed |
799 |
2021-12-15 11:48 |
Anonymous (not verified) |
74.84.79.78 |
Juan Martinez Slazar |
Proprietorship |
7085 Bloomfield Rd. Lot # 38 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-01 |
Juan A. Martinez Salazar |
juan50320@gmail.com |
Des Moines |
Polk |
Iowa |
Steve Young |
Logan Giudicessi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Juan A. Martinez Salazar |
juan50320@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Steve Young |
Logan Giudicessi |
Signed |
267 |
2020-09-22 07:04 |
Anonymous (not verified) |
74.84.65.174 |
Angel Jesus Argueta |
Proprietorship |
1523 Arlington Ave 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. |
2020-09-22 |
Angel Jesus Argueta |
Juanargueta22@yahoo.com |
Des Moines |
Polk |
Iowa |
Larry Eugene Guire |
Eric Michael West |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Angel Jesus Argueta |
Juanargueta22@yahoo.com |
Same |
Des Moines |
Polk |
Iowa |
Larry Eugene Guire |
Eric Michael West |
Signed |
1640 |
2023-05-11 07:42 |
Anonymous (not verified) |
94.188.205.168 |
Ibarra Drywall LLC |
Proprietorship |
1991 Holiday Rd, Coralville, IA 52241 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-11 |
Juan Reyes Ibarra |
juanreyes22031979@gmail.com |
Coralville |
Johnson |
Iowa |
Arcel Servin |
Chris Hay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Juan Reyes Ibarra |
juanreyes22031979@gmail.com |
Self |
Coralville |
Johnson |
Iowa |
Arcel Servin |
Chris Hay |
Signed |
1921 |
2023-11-22 12:14 |
Anonymous (not verified) |
94.188.205.177 |
Julie Drtina |
Proprietorship |
Cresco Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-22 |
Julie Drtina |
juliedrtina@hotmail.com |
Cresco |
Howard |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Julie Drtina |
juliedrtina@hotmail.com |
self |
Cresco |
Howard |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
481 |
2021-04-14 17:15 |
Anonymous (not verified) |
199.66.15.81 |
K3 Recycling |
Limited Liability Company |
601 W. 1st Ave. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-14 |
JUSTIN KAPPELMAN |
justin@kappelmanappliance.com |
Indianola |
Iowa |
Iowa |
Kristy Kappelman |
Charlie Kappelman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JUSTIN KAPPELMAN |
justin@kappelmanappliance.com |
Same person |
Indianola |
IA |
IA |
Kristy Kappelman |
Charlie Kappelman |
Signed |
937 |
2022-02-25 11:55 |
Anonymous (not verified) |
174.242.226.43 |
K3 Recycling |
Limited Liability Company |
510 West 2nd Ave. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-25 |
Justin Kappelman |
justin@kappelmanappliance.com |
Indianola |
Iowa |
Iowa |
Kristy Kappelman |
Charles Kappelman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Kappelman |
justin@kappelmanappliance.com |
Same |
Indianola |
Iowa |
Iowa |
Kristy Kappelman |
Charles Kappelman |
Signed |
1982 |
2024-01-11 12:29 |
Anonymous (not verified) |
94.188.205.166 |
Grace Justine |
Proprietorship |
405 Northview Drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-11 |
Grace Justine Wandera / Independent Contractor |
justine.wandera@candeoiowa.org |
Waukee |
IA |
IA |
Grace Justine Wandera / Independent Contractor |
Grace Justine Wandera / Independent Contractor |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Grace Justine Wandera / Independent Contractor |
justine.wandera@candeoiowa.org |
own |
Waukee |
IA |
IA |
Grace Justine Wandera / Independent Contractor |
Grace Justine Wandera / Independent Contractor |
Signed |
205 |
2020-07-15 14:19 |
Anonymous (not verified) |
108.209.12.64 |
Sequoia integrative Medical Services |
Limited Liability Company |
1746 Paul Drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-15 |
Jennifer Christine VandenHeuvel |
jvandenheuvel@att.net |
Kaukauna |
WI |
United States |
David VandenHeuvel |
Pam Leplavy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jennifer Christine VandenHeuvel |
jvandenheuvel@att.net |
Owner |
Kaukauna |
WI |
United States |
David VandenHeuvel |
Pam Leplavy |
Signed |
1973 |
2024-01-02 17:05 |
Anonymous (not verified) |
94.188.207.227 |
Diego Puente |
Proprietorship |
1420 north st, apt#3 Perry Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-02 |
Diego Puente Martinez |
diegopuente0655@gmail.com |
Perry |
Dallas |
Iowa |
Jason Van Dyke |
Ashley Heffernen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jason Van Dyke |
jvandyke@thermalshop.com |
worker |
Cedar Rapids |
Iowa |
United States |
Jason Van Dyke |
Ashley Heffernen |
Signed |
2195 |
2024-04-30 15:31 |
Anonymous (not verified) |
94.188.205.166 |
Jason Cooper |
Proprietorship |
1181 Western Ave Stockton Iowa 52769 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-30 |
Jason cooper |
jvcpainting88@gmail.com |
Stockton |
IA |
United States |
Violet minssen |
Hope Bishop |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jason cooper |
jvcpainting88@gmail.com |
Self |
Stockton |
IA |
United States |
Violet minssen |
Hope Bishop |
Signed |
1664 |
2023-05-25 13:18 |
Anonymous (not verified) |
94.188.207.227 |
Jason Vreeman |
Proprietorship |
5571 170th St sibley 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. |
2023-05-25 |
Jason Vreeman |
jvreeman21@gmail.com |
Sibley |
Osceola |
IA |
Katie Vreeman |
Jerry vreeman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jason Vreeman |
jvreeman21@gmail.com |
Self |
Sibley |
Osceola |
IA |
Katie Vreeman |
Jerry vreeman |
Signed |
1537 |
2023-03-27 13:21 |
Anonymous (not verified) |
94.188.207.228 |
miller hybrids |
Limited Liability Company |
1213 Larch Ave, Kalona, IA 52247 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-01 |
Jeremy Wakerhauser |
jwakerhauser@gmail.com |
Sun Prairie |
WI |
United States |
Jeremy Wakerhauser |
Jeremy Wakerhauser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeremy Wakerhauser |
jwakerhauser@gmail.com |
sole proprieter |
Sun Prairie |
WI |
United States |
Jeremy Wakerhauser |
Jeremy Wakerhauser |
Signed |
1613 |
2023-04-27 13:57 |
Anonymous (not verified) |
94.188.207.227 |
Jacob's Ladder Construction |
Proprietorship |
406 10th st Dallas Center Ia 50063 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-27 |
Jacob Willis |
jwillis924@gmail.com |
Dallas Center |
IA |
United States |
Anibal Bonilla |
Ed Willis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jacob A Willis |
jwillis924@gmail.com |
Owner |
Dallas Center |
IA |
United States |
Anibal Bonilla |
Ed Willis |
Signed |
568 |
2021-07-09 09:26 |
Anonymous (not verified) |
184.12.14.229 |
SS Docks LLC |
Limited Liability Company |
P.O. Box 561 Okoboji, IA 51355-0561 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-05-21 |
Jason Snow |
k.kooima@q.com |
Okoboji |
Dickinson |
Iowa |
Mabel Behnke |
Brandi Parks |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jason Snow - SS Docks LLC |
k.kooima@q.com |
Owner |
Okoboji |
Dickinson |
Iowa |
Mabel Behnke |
Brandi Parks |
Signed |
593 |
2021-08-03 12:29 |
Anonymous (not verified) |
184.12.14.229 |
SS Docks LLC |
Limited Liability Company |
PO Box 561, Okoboji, IA 51355-0561 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-05-21 |
Jason Snow |
k.kooima@q.com |
Okoboji |
Dickinson |
Iowa |
Mabel Behnke |
Brandi Parks |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jason Snow - SS Docks LLC |
k.kooima@q.com |
Owner |
Okoboji |
Dickinson |
Iowa |
Mabel Behnke |
Brandi Parks |
Signed |
2221 |
2024-05-13 09:26 |
Anonymous (not verified) |
94.188.207.226 |
Chad matthews |
Proprietorship |
3000 Justin dr. Suite J |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2024-05-13 |
Chad matthews |
kaceno2269@gmail.com |
Urbandale |
IA |
United States |
Sheri Frazier |
Terry warren |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Chad Matthews |
kaceno2269@gmail.com |
None |
Urbandale |
IA |
United States |
Sheri Fraiser |
Terry Warren |
Signed |
647 |
2021-09-20 10:37 |
Anonymous (not verified) |
173.29.34.49 |
Brandon Jones |
Proprietorship |
2043 3x 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. |
2021-09-20 |
Brandon Dederick Jones |
Kaleb0430jones@gmail.com |
East Moline |
United States |
Illinois |
Brandon Jones |
Brandon Jones |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brandon Dederick Jones |
Kaleb0430jones@gmail.com |
self |
East Moline |
United States |
Illinois |
Brandon Jones |
Brandon Jones |
Signed |
1384 |
2022-12-08 13:11 |
Anonymous (not verified) |
172.58.81.43 |
Sehic G&S, LLC. |
Limited Liability Company |
4201 62nd st apt 4 Urbandale Ia 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. |
2022-12-09 |
Bajro sehic |
kalesija20@gmail.com |
Urbandale |
Polk |
Iowa |
N/A |
N/A |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bajro sehic |
kalesija20@gmail.com |
Owner |
Urbandale |
Polk |
Iowa |
N/A |
N/A |
Signed |
1395 |
2022-12-15 08:02 |
Anonymous (not verified) |
172.58.84.122 |
Sehic G&S, LCC |
Limited Liability Company |
4201 62nd st 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. |
2022-12-15 |
Bajro sehic |
kalesija20@gmail.com |
Urbandale |
Polk |
Iowa |
Bajro |
Bajro |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bajro sehic |
kalesija20@gmail.com |
Owner |
Urbandale |
Dallas |
Iowa |
Bajro |
Bajro |
Signed |
300 |
2020-10-30 10:51 |
Anonymous (not verified) |
216.51.132.207 |
Joe Kann & Luke Kann |
Partnership |
32256 Leaf Rd Guttenberg IA 52052 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-28 |
Joe Kann |
kannbros1895@gmail.com |
Guttenberg |
Clayton |
Iowa |
Jerry J Rochford |
Nicole L Parker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joe Kann |
kannbros1895@gmail.com |
owner |
Guttenberg |
Clayton |
Iowa |
Jerry J Rochford |
Nicole L Parker |
Signed |
301 |
2020-10-30 10:53 |
Anonymous (not verified) |
216.51.132.207 |
Joe Kann & Luke Kann |
Partnership |
32256 Leaf Rd Guttenberg IA 52052 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-27 |
Luke Kann |
kannbros1895@gmail.com |
Guttenberg |
Clayton |
Iowa |
Jerry J Rochford |
Nicole L Parker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luke Kann |
kannbros1895@gmail.com |
owner |
Guttenberg |
Clayton |
Iowa |
Jerry J Rochford |
Nicole L Parker |
Signed |
1476 |
2023-02-22 12:23 |
Anonymous (not verified) |
94.188.205.174 |
KARL INGWERSEN |
Proprietorship |
2716 FRANCIS SITES DR SPIRIT LAKE, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-22 |
KARL INGWERSEN |
KARL58INGWERSEN@GMAIL.COM |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KARL INGWERSEN |
KARL58INGWERSEN@GMAIL.COM |
SELF |
SPIRIT LAKE |
DICKSINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
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 |
2047 |
2024-02-15 16:58 |
Anonymous (not verified) |
94.188.205.177 |
PorchLight Insights LLC |
Limited Liability Company |
2918 Campbell Street, Kansas City, MO 64109 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-15 |
Kate Regnier Bender |
kate.bender@porchlightinsights.com |
Kansas City |
Jackson |
Missouri |
Jonathan Bender |
Brandon Steenson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kate Regnier Bender |
kate.bender@porchlightinsights.com |
Co-Founder |
Kansas City |
Jackson |
Missouri |
Jonathan Bender |
Brandon Steenson |
Signed |
1136 |
2022-05-31 13:46 |
Anonymous (not verified) |
173.31.148.43 |
OKOBOJI BURRITO COMPANY LLC |
Limited Liability Company |
39502 710TH ST LAKEFIELD, MN 56105 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-26 |
KATHRYN SCHULTZ |
kathrynlucier@ymail.com |
LAKEFIELD |
JACKSON |
MN |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KATHRYN SCHULTZ |
kathrynlucier@ymail.com |
SELF |
LAKEFIELD |
JACKSON |
MN |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1826 |
2023-08-30 16:38 |
Anonymous (not verified) |
94.188.207.227 |
IOWA MOLD REMOVAL |
Limited Liability Company |
103 15TH ST SW, ALTOONA, IA 50009 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-30 |
RHETT OSELETTE |
RHETT.OSELETTE@GMAIL.COM |
CLIVE |
DALLAS |
IOWA |
ELLA OSELETTE |
MYA OSELETTE |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KATIE BROWN |
KATIE@IOWAMOLDREMOVAL.COM |
EMPLOYER |
ALTOONA |
POLK |
IOWA |
MYA OSELETTE |
ELLA OSELETTE |
Signed |
1758 |
2023-07-20 16:37 |
Anonymous (not verified) |
94.188.205.174 |
Nailed It Remodeling Services LLC |
Limited Liability Company |
1520 Burnett Ave Ames, IA 50010 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-20 |
Kaylyn Christianson |
kaylynchristianson@gmail.com |
Ames |
Story |
Iowa |
Jon Buller |
Terry Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kaylyn Christianson |
KaylynChristianson@gmail.com |
Manager |
Ames |
Story |
Iowa |
Jon Buller |
Terry Miles |
Signed |
862 |
2022-01-27 12:02 |
Anonymous (not verified) |
174.198.81.166 |
Big Bear Construction,LLC |
Limited Liability Company |
4508 Hiawatha Ave NE Cedar Rapids, IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-27 |
Michael Allen Becker |
mike4bbc@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Kenny McCracken |
Corey Becker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kevin Paul Becker jr |
kbeckerbbc@gmail.com |
Brother/partner |
Cedar Rapids |
Linn |
Iowa |
Kenny McCracken |
Corey Becker |
Signed |
700 |
2021-10-29 11:04 |
Anonymous (not verified) |
174.198.66.50 |
T&C Lawn Care LLC |
Limited Liability Partnership |
1827 Black Hawk St Waterloo IA 50702 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-29 |
Cody R Woodley |
cody.woodley50@gmail.com |
Cedar Falls |
Blackhawk |
Iowa |
Tara R Woodley |
Sara Woodley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kristi S. Demuth Agency, Inc. |
kdemuth@amfam.com |
Client |
Waverly |
Bremer |
Iowa |
Cody R Woodley |
Tyler M Croft |
Signed |
1677 |
2023-06-02 11:37 |
Anonymous (not verified) |
94.188.207.230 |
Karl Klotzbach |
Proprietorship |
403 Jefferson, Decorah IA 52101 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-02 |
Karl Klotzbach |
kdklotzbach@gmail.com |
Decorah |
Winneshiek |
Iowa |
Robin Schultz |
Jane Regan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Karl Klotzbach |
kdklotzbach@gmail.com |
Employer |
Decorah |
Winneshiek |
Iowa |
Robin Schutlz |
Jane M Regan |
Signed |
2077 |
2024-03-06 11:08 |
Anonymous (not verified) |
94.188.205.177 |
Randy's all Right painting |
Proprietorship |
24531n.ave Dallas center iowa po 445 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-06 |
David keasey |
keaseyshideaway@gmail.com |
Dallas center |
Dallas |
Iowa |
Angela Johnston |
Robin Vilz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David keasey |
keaseyshideaway@gmail.com |
Self |
Dallas center |
Dallas |
Iowa |
Angela Johnston |
Robin Volz |
Signed |
1059 |
2022-04-19 15:06 |
Anonymous (not verified) |
64.186.23.83 |
CORRECTIONVILL GOLF CLUB, INC |
Limited Liability Company |
1300 HACKBERRY STREET, CORRECTIONVILLE IOWA 51016 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-19 |
NICK HEATH |
dogboy3485@yahoo.com |
CORRECTIONVILLE |
WOODBURY |
IOWA |
CANDACE JACOBSON |
AMBER HANSEN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KATIE EDWARDS |
kedwards@fnbcorrectionville.com |
SEC/TREASURER |
CORRECTIONVILLE |
WOODBURY |
IOWA |
CANDACE JACOBSON |
AMBER HANSEN |
Signed |
1060 |
2022-04-19 15:08 |
Anonymous (not verified) |
64.186.23.83 |
CORRECTIONVILLE GOLF CLUB, INC |
Limited Liability Company |
1300 HACKBERRY STREET, CORRECTIONVILLE IOWA 51016 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-19 |
ADAM KELLY |
dslkraz@gmail.com |
CORRECTIONVILLE |
WOOD |
IWOA |
CANDACE |
AMBER HANSEN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KATIE EDWARDS |
kedwards@fnbcorrectionville.com |
SEC/TREASURER |
CORRECTIONVILLE |
WOODBURY |
IOWA |
CANDACE JACOBSON |
AMBER HANSEN |
Signed |
2148 |
2024-04-15 11:15 |
Anonymous (not verified) |
94.188.207.224 |
Derek Fetzer |
Proprietorship |
360 250th St, West Branch, IA 52358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-12-17 |
Dere W Fetzer |
kellylanz1967@gmail.com |
West Branch |
IA |
United States |
Maribelle Lund |
Carl Lund |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derek Fetzer |
kellylanz1967@gmail.com |
Self |
West Branch |
IA |
United States |
Maribelle Lund |
Carl Lund |
Signed |
2149 |
2024-04-15 11:20 |
Anonymous (not verified) |
94.188.207.224 |
Grady Yeggy |
Proprietorship |
211 3rd St. Riverside, IA 52327 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-12-11 |
Grady S Yeggy |
kellylanz1967@gmail.com |
Riverside |
IA |
United States |
Amanda Yeggy |
Leah Evans |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Grady S Yeggy |
kellylanz1967@gmail.com |
Self |
Riverside |
IA |
United States |
Amanda Yeggy |
Leah Yeggy |
Signed |
2150 |
2024-04-15 12:07 |
Anonymous (not verified) |
94.188.205.177 |
Todd E Holsteen |
Proprietorship |
16015 Hwy 99, Burlington, IA 52601 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-28 |
Todd E Holsteen |
kellylanz1967@gmail.com |
Burlington |
IL |
United States |
David Steele |
Kari Holsteen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Todd E Holsteen |
kellylanz1967@gmail.com |
Self |
Burlington |
IA |
United States |
David Steele |
Kari Holsteen |
Signed |
2153 |
2024-04-15 21:59 |
Anonymous (not verified) |
94.188.205.167 |
Ethan M Hoffman |
Proprietorship |
1442 N. County RD 800, Hamilton, IL 62341 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-07 |
Ethan M Hoffman |
kellylanz1967@gmail.com |
Hamilton |
IL |
United States |
Gay Hoffman |
Debra Kelley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ethan M Hoffman |
kellylanz1967@gmail.com |
Self |
Hamilton |
IL |
United States |
Gay Hoffman |
Debra Kelley |
Signed |
2154 |
2024-04-16 08:05 |
Anonymous (not verified) |
94.188.207.226 |
Lanz Pork Inc |
Proprietorship |
12905 N 1050th Road, Macomb, IL 61455 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-02 |
Andrew M Riggins |
kellylanz1967@gmail.com |
Macomb |
IL |
United States |
Barb Coker |
Scott Caspall |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andrew M Riggins |
kellylanz1967@gmail.com |
Self |
Macomb |
IL |
United States |
Barb Coker |
Scott Caspall |
Signed |
2155 |
2024-04-16 08:13 |
Anonymous (not verified) |
94.188.207.225 |
Andrew M Riggins |
Proprietorship |
12905 N 1050th Road, Macomb, IL 61455 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-02 |
Andrew M Riggins |
kellylanz1967@gmail.com |
Macomb |
IL |
United States |
Barb Coker |
Scott Caspall |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andrew M Riggins |
kellylanz1967@gmail.com |
Self |
Macomb |
IL |
United States |
Barb Coker |
Scott Caspall |
Signed |
715 |
2021-11-05 11:27 |
Anonymous (not verified) |
209.252.172.87 |
Ken Clifford |
Proprietorship |
132121st Ave SW Cedar Rapids, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-18 |
Ken Clifford |
ken40406108@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ken Clifford |
ken40406108@gmail.com |
Self Employer |
Cedar Rapids |
Linn |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
535 |
2021-06-04 13:16 |
Anonymous (not verified) |
192.119.129.187 |
KMA Communications, LLC |
Limited Liability Company |
435 croston rd. Stockport, OH 43787 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-04 |
Kenneth Stephen Alsup |
kenneth.alsup@yahoo.com |
Walker |
Wood |
West Virginia |
Stephen Alsup |
Nancy Alsup |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kenneth Stephen Alsup |
kenneth.alsup@yahoo.com |
Same Person |
Walker |
Wood |
West Virginia |
Stephen Alsup |
Nancy Alsup |
Signed |
845 |
2022-01-20 09:06 |
Anonymous (not verified) |
208.126.69.10 |
KenX Pest Control |
Limited Liability Company |
350 2nd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-20 |
Ken YARRINGTON |
kenxpestcontrol@hotmail.com |
Truro |
IA |
IA |
James Gage |
Kent Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kenneth Charles Yarrington |
kenxpestcontrol@hotmal.com |
Myself |
Truro |
IA |
IA |
James Gage |
Kent Smith |
Signed |
191 |
2020-06-23 16:09 |
Anonymous (not verified) |
173.18.3.76 |
Look At You LLC |
Limited Liability Company |
5545 Mills Civic Pkwy Ste 100 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. |
2020-06-23 |
Amber Keppler |
keppler_ark@outlook.com |
Des Moines |
Polk |
IA |
Angela Kinsey |
Jon Stetzel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Amber Keppler |
keppler_ark@outlook.com |
LLC Member |
Des Moines |
Polk |
IA |
Angela Kinsey |
Jon Stetzel |
Signed |
523 |
2021-05-17 21:46 |
Anonymous (not verified) |
173.29.90.123 |
Nick keppy |
Proprietorship |
2103 e Lombard st. Davenport iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-17 |
Nick keppy |
keppylawncare@gmail.com |
Davenport |
Scott |
Iowa |
Logan keppy |
Rebecca Hein |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nick keppy |
keppylawncare@gmail.com |
Self |
Davenport |
Scott |
Iowa |
Logan keppy |
Rebecca hein |
Signed |
1242 |
2022-08-03 14:53 |
Anonymous (not verified) |
107.141.197.247 |
Hygieia Stainless Solutions LLC |
Limited Liability Company |
2200 Blairsferry Crossing Hiawatha, IA 52233 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-08-03 |
Kevin R Dibel |
kevin.dibel@hygieiastainless.com |
Lebanon |
Wilson |
Tennessee |
Andy Scanlon |
Roger Batterson |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Kevin R Dibel |
kevin.dibel@hygieiastainless.com |
self |
Lebanon |
Wilson |
Tennessee |
Andy Scanlon |
Roger Batterson |
Signed |
451 |
2021-03-25 17:00 |
Anonymous (not verified) |
166.181.80.120 |
Rogers conc,. const, |
Partnership |
220804 CO, RD, ANAMOSA IA, 52205 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-25 |
Alex olah |
aolah43@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Robin marie kane |
Augie rodreguez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kevin johnson |
kevinecollins@libertymutual.com |
Ins , Agent |
Appleton |
Dane |
Wisconsin |
Robin marie kane |
Augie Rodriguez |
Signed |
452 |
2021-03-26 07:30 |
Anonymous (not verified) |
173.31.109.49 |
Rogers Concrete Construction |
Partnership |
22802 County Rd E34 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-26 |
Alexander Olah |
aolah43@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Robin Marie Kane |
Augies Rodrigez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kevin Johnson |
kevinjohnson@libertymutual.com |
Insurance Agent |
Appleton |
Outagamie |
Wisconsin |
Robin Marie Kane |
Augie Rodrigez |
Signed |
2006 |
2024-01-29 11:04 |
Anonymous (not verified) |
94.188.207.224 |
Kevin Jones |
Proprietorship |
1500 15Th St. Milford IA 51351 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-29 |
KEVIN JONES |
KEVINMJONES81@GMAIL.COM |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JOSEPH LORING |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KEVIN JONES |
KEVINMJONES81@GMAIL.COM |
SELF |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JOSEPH LORING |
Signed |
2010 |
2024-01-30 11:46 |
Anonymous (not verified) |
94.188.207.230 |
Kevin & Jlynn Jones |
Proprietorship |
1500 15th St. Milford Ia 51351 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-30 |
Jlynn Jones |
KEVINMJONES81@GMAIL.COM |
Milford |
Dickinson |
Iowa |
Tami Klein |
Joseph Loring |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kevin & Jlynn Jones |
KEVINMJONES81@GMAIL.COM |
Self |
Milford |
Dickinson |
Iowa |
Tami Klein |
Joseph Loring |
Signed |
964 |
2022-03-10 12:41 |
Anonymous (not verified) |
107.115.239.27 |
KG Land Works LLC |
Limited Liability Company |
P.O. Box 931 Barnsdall Ok 74002 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-10 |
Colton Kelley |
kglandworks@gmail.com |
Barnsdall |
Osage |
Oklahoma |
Colton Kelley |
Dalton Gardner |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Colton Kelley |
kglandworks@gmail.com |
Owner |
Barnsdall |
Osage |
Oklahoma |
Colton Kelley |
Dalton Gardner |
Signed |
965 |
2022-03-10 12:44 |
Anonymous (not verified) |
107.115.239.27 |
KG Land Works LLC |
Limited Liability Company |
P.O. Box 931 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-10 |
Dalton Gregory Gardner |
kglandworks@gmail.com |
Barnsdall |
Osage |
Oklahoma |
Dalton Gardner |
Colton Kelley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dalton Gardner |
kglandworks@gmail.com |
Owner |
Barnsdall |
Osage |
Oklahoma |
Dalton Gardner |
Colton Kelley |
Signed |
1032 |
2022-04-05 09:21 |
Anonymous (not verified) |
75.89.4.2 |
KG land works |
Limited Liability Company |
812 cr 2401 barnsdall Oklahoma 74002 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-05 |
Wyatt ray slone |
wyattslone177@gmail.com |
Barnsdalll |
Osage |
OK |
Dalton Gardner |
Colton Kelley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Colton Kelley |
kglandworks@gmail.com |
Day helper |
Barnsdalll |
Osage |
OK |
Colton Kelley |
Dalton Gardner |
Signed |
1033 |
2022-04-05 09:36 |
Anonymous (not verified) |
75.89.4.2 |
KG Land Works |
Limited Liability Company |
PO Box 931 Barnsdall, Oklahoma 74002 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-05 |
Jacob Curtis Kelley |
jacobkelley730@gmail.com |
Barnsdall |
Osage |
Oklahoma |
Josiah Daniel Gott |
Ainsley Noelle Cunningham |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dalton Gardner |
kglandworks@gmail.com |
Owner |
Barnsdall |
Osage |
Oklahoma |
Josiah Daniel Gott |
Wyatt Ray Slone |
Signed |
1121 |
2022-05-19 17:45 |
Anonymous (not verified) |
107.115.239.35 |
KG Land works LLC |
Limited Liability Company |
P.O. Box 931Barnsdall Oklahoma 74002 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-19 |
Keiven Brooke Slone |
keiven.slone@gmail.com |
Barnsdalll |
Osage |
OK |
Colton Kelley |
Dalton Gardner |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Colton Kelley |
kglandworks@gmail.com |
Owner |
Barnsdalll |
Osage |
OK |
Dalton Garder |
Jacob Kelley |
Signed |
1196 |
2022-07-11 08:13 |
Anonymous (not verified) |
166.181.85.207 |
KG Land works |
Proprietorship |
P.O. Box 931 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-12 |
Noah Wassom |
nowhwassom@yahoo.com |
Barnsdall |
Osage |
OKLAHOMA |
Dalton Gardner |
Jacob Kelley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Colten Kelley |
KGlandworks@gmail.com |
Boss |
Barnsdall |
Osage |
OKLAHOMA |
Keiven Slone |
Whyatt Slone |
Signed |
1575 |
2023-04-16 09:00 |
Anonymous (not verified) |
94.188.205.176 |
Velocity Improvement, LLC |
Proprietorship |
PO Box 903, Wilton IA 52778 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-16 |
Kent Grunhovd |
velocityimprovement@gmail.com |
Wilton |
Scott |
Iowa |
Robin Throne |
LaVonne Grunhovd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kent Grunhovd |
kgrunhovd3535@gmail.com |
Self |
Bloomington |
McLean |
IL |
Robin Throne |
LaVonne Grunhovd |
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 |
1374 |
2022-11-17 14:33 |
Anonymous (not verified) |
72.106.129.202 |
Cowman Consulting and Construction LLC |
Limited Liability Company |
740 NE Horizon Dr, Waukee IA 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. |
2022-11-17 |
Khalid Cowman |
khalidcowman1@gmail.com |
Waukee |
Dalls |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Khalid Cowman |
khalidcowman1@gmail.com |
Self/Owner |
Waukee |
Dallas |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
839 |
2022-01-14 10:56 |
Anonymous (not verified) |
173.29.218.216 |
Midwest Solar Services, LLC |
Limited Liability Company |
595 Huff Street, 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-01-10 |
Tyler Billmeyer |
tbillmeyer@midwestsolarservices.com |
Dubuque |
Dubuque |
Iowa |
Kim Esser |
Michelle Huss |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Midwest Solar Services, LLC |
kim.esser@kunkel-inc.com |
Insurance Agent |
Dubuque |
Dubuque |
Iowa |
Kim Esser |
Michelle Huss |
Signed |
840 |
2022-01-14 10:58 |
Anonymous (not verified) |
173.29.218.216 |
Midwest Solar Services, LLC |
Limited Liability Company |
595 Huff Street, 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-01-10 |
Matthew Shear |
mshear@midwestsolarservices.com |
Dubuque |
Dubuque |
Iowa |
Kim Esser |
Michelle Huss |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Midwest Solar Services, LLC |
kim.esser@kunkel-inc.com |
Insurance Agent |
Dubuque |
Dubuque |
Iowa |
Kim Esser |
Michelle Huss |
Signed |
841 |
2022-01-14 15:23 |
Anonymous (not verified) |
173.29.218.216 |
Midwest Solar Services, LLC |
Limited Liability Company |
595 Huff Street, 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-01-10 |
Matthew Shear |
mshear@midwestsolarservices.com |
Hanover |
Jo Daviess |
IL |
Kim Esser |
Michelle Huss |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Midwest Solar Services, LLC |
kim.esser@kunkel-inc.com |
Insurance Agent |
Dubuque |
Dubuque |
Iowa |
Kim Esser |
Michelle Huss |
Signed |
1164 |
2022-06-23 09:26 |
Anonymous (not verified) |
74.84.106.106 |
Kimberly Owens |
Proprietorship |
2503 E 23rd street Newton, IA 50228 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-23 |
Kimberly Owens |
kimmybobby1220@gmail.com |
Newton |
Jasper |
Iowa |
Rita Littrell |
Tina Owens |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kimberly Owens |
kimmybobby1220@gmail.com |
Self |
Newton |
Jasper |
Iowa |
Rita Littrell |
Tina Owens |
Signed |
909 |
2022-02-10 08:03 |
Anonymous (not verified) |
166.181.83.242 |
Kim Hildebrand |
Proprietorship |
130 Sabrina cir Waterloo, IA 50703 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-07 |
Kimberly Kay Hildebrand |
kimregenold@yahoo.com |
Waterloo |
Blackhawk |
Iowa |
Darrin Hildebrand |
Stephanie Nerison |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kimberly Kay Hildebrand |
kimregenold@yahoo.com |
Self |
Waterloo |
Blackhawk |
Iowa |
Darrin Hildebrand |
Stephanie Nerison |
Signed |
147 |
2020-05-02 09:07 |
Anonymous (not verified) |
75.162.65.142 |
Tim Soy |
Proprietorship |
3506 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. |
2020-05-01 |
Timothy Soy |
kingsoyboy@hotmail.com |
Des Moines |
Polk |
Iowa |
Aaron Page |
Jeremy Lukehart |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy Soy |
kingsoyboy@hotmail.com |
Self |
Des Moines |
Polk |
Iowa |
Aaron page |
Jeremy Lukehart |
Signed |
1634 |
2023-05-10 07:21 |
Anonymous (not verified) |
94.188.205.174 |
KS Drywall |
Proprietorship |
404 E Jayne Street Lone Tree, IA 52755 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-10 |
Kirk Strunk |
kirkstrunk@gmail.com |
Lone Tree |
Johnson |
Iowa |
Chris Hay |
Brad Bower |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kirk Strunk |
kirkstrunk@gmail.com |
Self |
Lone Tree |
Johnson |
Iowa |
Chris Hay |
Brad Bower |
Signed |
908 |
2022-02-09 15:06 |
Anonymous (not verified) |
63.152.66.183 |
Shear Texture |
Limited Liability Company |
1427 A Ave NW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-09 |
Wendy Kiser |
kiser187@msn.com |
Cedar Rapids |
Linn |
Iowa |
Shelly Wehr |
Kimberly Erickson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wendy Kiser |
kiser187@msn.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Shelly Wehr |
Kimberly Erickson |
Signed |
1480 |
2023-02-24 08:54 |
Anonymous (not verified) |
94.188.205.176 |
Shear Texture |
Limited Liability Company |
2000 Wiley Blvd SW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-24 |
Wendy Kiser |
kiser187@msn.com |
Cedar Rapids |
Linn |
Iowa |
Kim Erickson |
Shauna Whitaker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wendy Kiser |
kiser187@msn.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Kim Erickson |
Shauna Whitaker |
Signed |
2087 |
2024-03-11 09:39 |
Anonymous (not verified) |
94.188.205.175 |
Shear Texture |
Limited Liability Company |
2000 Wiley Blvd SW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2024-03-11 |
Wendy Kiser |
kiser187@msn.com |
Cedar Rapids |
Linn |
Iowa |
Kim Erickson |
Shauna Whitaker |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Wendy Kiser |
kiser187@msn.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Kim Erickson |
Shauna Whitaker |
Signed |
1249 |
2022-08-09 14:14 |
Anonymous (not verified) |
166.181.82.131 |
Kelly Kellogg |
Proprietorship |
1305 N 1st st apt 16 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-09 |
Kelly Kellogg |
Kkell0223@gmail.com |
Indianola |
Warren |
Iowa |
Kelly Kellogg |
Amy Kellogg |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kelly's Flooring |
Kkell0223@gmail.com |
Myself |
1305 N 1st st apt 16 |
Warren |
Iowa |
Kelly Kellogg |
Amy Kellogg |
Signed |
1942 |
2023-12-06 13:45 |
Anonymous (not verified) |
94.188.207.228 |
K&K Service |
Limited Liability Company |
6125 R57 Hwy Indianola, IA 50125 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-06 |
Keaton Klocko |
kklocko30@aim.com |
Indianola |
Warren |
Iowa |
Kourtne Klocko |
Mallory Metzger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Keaton Klocko |
kklocko30@aim.com |
Owner |
Indianola |
Warren |
Iowa |
Kourtne Klocko |
Mallory Metzger |
Signed |
570 |
2021-07-09 16:42 |
Anonymous (not verified) |
184.12.14.229 |
SS Docks LLC |
Limited Liability Company |
P.O. Box 561 Okoboji, IA 51355-0561 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-05-21 |
Jason Snow |
kkooima@q.com |
Okoboji |
Dickinson |
Iowa |
Mabel Behnke |
Brandi Parks |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jason Snow - SS Docks LLC |
kkooima@q.com |
Owner |
Okoboji |
Dickinson |
Iowa |
Mabel Behnke |
Brandi Parks |
Signed |
378 |
2021-01-29 11:43 |
Anonymous (not verified) |
50.82.21.136 |
GRAPHIX MASTERS |
Limited Liability Company |
420 Hamilton St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-01-29 |
Klayton Karl Kirkpatrick |
klay@graphixmasters.us |
Ottumwa |
IA |
United States |
Brian Wilson |
Aimee Kirkpatrick |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Klayton Kirkpatrick |
klay@graphixmasters.us |
Same |
Ottumwa |
Iowa |
United States |
Brian Wilson |
Aimee Kirkpatrick |
Signed |