334 |
2020-12-07 12:38 |
Anonymous (not verified) |
173.19.190.160 |
Broadband Installations of Iowa LLC |
Limited Liability Company |
P.O. Box 728 Carroll, IA 51401 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-07 |
Charles Wood |
cwood.bband@outlook.com |
CEDAR RAPIDS |
IA |
IA |
Eva Wood |
Tamara Wood |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Skyla Siech |
skylabbi@outlook.com |
Offcie Manager |
Ely |
Linn |
Iowa |
Melvin Harter |
Eddie Bell |
Signed |
1318 |
2022-09-22 11:18 |
Anonymous (not verified) |
50.82.91.213 |
J. Thompson Builders, LLC |
Limited Liability Company |
5291 Stoney Creek Ct. Johnston, IA 50131 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-22 |
Christopher Jacob Von Arx |
cjvonarx@hotmail.com |
Van Wert IA |
Decatur IA |
Iowa |
Christina Viehauser |
Jeremy Thompson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christina Viehauser |
christina@jthompsonbuilders.com |
Office Help |
Johnston Ia |
Polk |
IA |
Chris Von Arx |
Jeremy Thompson |
Signed |
1319 |
2022-09-22 11:31 |
Anonymous (not verified) |
50.82.91.213 |
J. Thompson Builders, LLC |
Limited Liability Company |
5291 Stoney Creek Ct. Johnston, IA 50131 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-22 |
Mark Grant |
mjgrant1957@gmail.com |
Adel |
Dallas |
IA |
Christina Viehauser |
Jeremy Thompson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christina Viehauser |
christina@jthompsonbuilders.com |
Office Help |
Johnston Ia |
Polk |
IA |
Chris Von Arx |
Jeremy Thompson |
Signed |
178 |
2020-06-08 13:51 |
Anonymous (not verified) |
173.21.16.200 |
Daniel Mullanack |
Limited Liability Company |
1208 Franklin St. Buffalo, IA 52728 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2020-06-08 |
daniel mullanack |
mullanackbuilders@mediacombb.net |
buffalo |
scott |
iowa |
brandon brooks |
amy carlson |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
linda mullanack |
mullanackbuilders@mediacombb.net |
office manager |
buffalo |
scott |
iowa |
brandon brooks |
amy carlson |
Signed |
376 |
2021-01-26 11:14 |
Anonymous (not verified) |
173.28.210.45 |
Cross Medical Lab, L.L.P |
Limited Liability Partnership |
500 E Market St Iowa City IA 52240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-26 |
Aaron Klein |
lhavel_23@gmail.com |
Iowa City |
Johnson |
Iowa |
Ashley Lee |
Dan Wegman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lori Havel |
lhavel_23@gmail.com |
Office Manager |
Iowa CIty |
Johnson |
IA |
Ashley Lee |
Dan Wegman |
Signed |
506 |
2021-05-10 09:29 |
Anonymous (not verified) |
199.102.211.129 |
Nathan J Hurst LLC DBA J&K Construction |
Limited Liability Company |
3598 Orchard Rd. Osage, IA 50461 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-10 |
Nathan J Hurst |
jkconstructionjake@yahoo.com |
Osage |
Mitchell |
Iowa |
Breanna Fox |
Karl Herman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Breanna Fox |
jkconstructionjake@yahoo.com |
Office Manager |
Osage |
Mithell |
Iowa |
Nathan J Hurst |
Karl F Herman |
Signed |
654 |
2021-09-24 15:08 |
Anonymous (not verified) |
199.247.64.87 |
Steve Porter DBA Precision Striping |
Proprietorship |
408 Embassy Ct. Sergeant Bluff, IA 51054 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-23 |
Steve Porter |
steve.porter2710@gmail.com |
Sergeant Bluff |
Woodbury |
Iowa |
Josh Nichols |
Steve Porter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jana Reich |
JNeuzil@reichpainting.com |
Office Manager |
Sioux City |
Woodbury |
Iowa |
Josh Nichols |
Steve Porter |
Signed |
731 |
2021-11-09 14:08 |
Anonymous (not verified) |
166.181.87.107 |
Leaf Filter North |
Limited Liability Company |
3060 SE Grimes Blvd, STE 100 Grimes, IA 50111 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-09 |
Jordan Cunningham |
jcunnsalvage@gmail.com |
Baxter |
Jasper |
Iowa |
Karen Cunningham |
Makenzie Raridon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Megan McIlhon |
mmcilhon@leaffilter.com |
Office Manager |
Grimes |
Polk |
Iowa |
Karen Cunningham |
Makenzie Raridon |
Signed |
1864 |
2023-10-09 09:52 |
Anonymous (not verified) |
94.188.207.223 |
Admiral Staffing Inc |
Limited Liability Company |
580 8th Ave, 15th Floor, New York NY 10018 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-09 |
Rezwan Rafeek |
ray@admiralstaffinginc.com |
23 Catalpa Lane |
Valley Stream |
NY |
Ikbal Sherif |
Salim Balee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shafi Rafeek |
shafi@admiralstaffinginc.com |
Office Manager |
New York |
NY |
United States |
Ikbal Sherif |
Salin Balee |
Signed |
82 |
2020-02-25 17:32 |
Anonymous (not verified) |
66.43.239.175 |
Lynx Ag LLC |
Limited Liability Company |
510 H Ave, Churdan IA 50050 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-25 |
Lance Glendenning |
lanceandabby@wccta.net |
Churdan |
Greene |
Iowa |
Dena M. Anderson |
Shelly Brus |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Abby Glendenning |
lanceandabby@wccta.net |
Officer |
Churdan |
Greene |
IA |
Dena M Anderson |
Shelly Brus |
Signed |
417 |
2021-03-03 13:49 |
Anonymous (not verified) |
173.215.42.12 |
Lynx Ag LLC |
Limited Liability Company |
510 H Ave, Churdan IA 50050 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-03 |
Lance Jeffrey Glendenning |
lanceandabby@wccta.net |
Churdan |
Greene |
Iowa |
Shelly L. Brus |
Dena M. Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Abby Glendenning |
accounting@lynxag.com |
Officer |
Churdan |
Greene |
Iowa |
Shelly L. Brus |
Dena M. Anderson |
Signed |
971 |
2022-03-14 17:59 |
Anonymous (not verified) |
207.32.37.48 |
Lynx Ag LLC |
Limited Liability Company |
510 H Ave, Churdan, IA 50050 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-14 |
Lance Glendenning |
lanceandabby@wccta.net |
Churdan |
Greene |
Iowa |
Kim Kersey |
Shelly Brus |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Abby Glendenning |
accounting@lynxag.com |
Officer |
Churdan |
Greene |
Iowa |
Kim Kersey |
Shelly Brus |
Signed |
1392 |
2022-12-12 11:55 |
Anonymous (not verified) |
173.215.8.119 |
Jones OD PLLC |
Limited Liability Company |
17792 538th St Griswold, IA 51535 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-12-08 |
Travis Preston Jones |
jonesodpllc@gmail.com |
Griswold |
Pottawattamie |
Iowa |
Kirk Douglas Lantz |
Karla Kay Lantz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Preston Jones |
jonesodpllc@gmail.com |
Officer |
Griswold |
Pottawattamie |
Iowa |
Kirk Douglas Lantz |
Karla Kay Lantz |
Signed |
1834 |
2023-09-08 15:04 |
Anonymous (not verified) |
94.188.205.177 |
Ryan Tucker |
Proprietorship |
19000 hwy 69 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-08 |
Ryan Tucker |
rtlltucker@yahoo.com |
Indianola |
Warren |
Iowa |
Brooke Prior |
Aly Brose |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Tucker |
rtlltucker@yahoo.com |
Officer |
Indianola |
Warren |
Iowa |
Brooke Prior |
Aly Brose |
Signed |
2016 |
2024-02-01 09:20 |
Anonymous (not verified) |
94.188.207.225 |
Imperium Outdoor Solutions |
Proprietorship |
114 W Clanton St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-01 |
Austin Beener |
abeener033@gmail.com |
St Charles |
IA |
United States |
Austin Beener |
Austin Beener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Austin Beener |
abeener033@gmail.com |
Operator |
St Charles |
IA |
United States |
Austin Beener |
Austin Beener |
Signed |
1173 |
2022-06-27 14:44 |
Anonymous (not verified) |
162.253.44.28 |
Hardwood Design Co LLC |
Limited Liability Company |
75 Commercial Drive North Liberty Iowa 52317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-17 |
Rilen Carew |
hardwooddesignllc@gmail.com |
Coralville |
Johnson |
Iowa |
Joan Tobin |
Olivia Meier |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tyler Fisher |
hardwooddesignllc@gmail.com |
other member of LLC |
Coralville |
Johnson |
Iowa |
Joan Tobin |
Olivia Meier |
Signed |
1861 |
2023-10-05 10:14 |
Anonymous (not verified) |
94.188.207.227 |
Charles von Maur |
Proprietorship |
18325 Robbins Road Pleasant Valley IA 52767 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-05 |
Charles von Maur |
rlarsen@vonmaur.com |
Pleasant Valley |
Scott |
IA |
Robert L Larsen |
Amanda Bratthauer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert L Larsen |
rlarsen@vonmaur.com |
Outside consultant |
east moline |
Rock Island |
IL |
Josh Barnes |
Amanda Bratthauer |
Signed |
1668 |
2023-05-30 10:50 |
Anonymous (not verified) |
94.188.207.230 |
Projects Under Development LLC |
Limited Liability Company |
2516 Hickory Grove Rd Davenport Iowa 52804 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-30 |
James Stock |
jamese1053@gmail.com |
Davenport |
Scott |
Iowa |
Ronald Lang |
Karen Stock |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Stock |
jamese1053@gmail.com |
Owener |
Davenport |
Scott |
Iowa |
Ronald Lang |
Karen Walker |
Signed |
1159 |
2022-06-17 10:58 |
Anonymous (not verified) |
174.235.208.232 |
Vertex Construction Services |
Limited Liability Company |
1620 E Diehl Ave, 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. |
2022-06-17 |
William Dombrowski |
wdombrowski629@gmail.com |
Des moines |
Polk |
Iowa |
Clark Newbury |
Lisa Rodriguez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Dombrowski |
wdombrowski629@gmail.com |
Owmer |
Des moines |
Polk |
Iowa |
Clark Newbury |
Lisa Rodriguez |
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 |
6 |
2019-11-14 13:09 |
Anonymous (not verified) |
69.18.10.115 |
Sigourney Heating and Air Conditioning LLC |
Limited Liability Company |
106 E Washington, Sigourney Iowa 52591 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-11-14 |
Spencer A Wright |
officeshac@gmail.com |
Sigourney |
Keokuk |
Iowa |
Darren Diethelm |
Myles Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Spencer A Wright |
officeshac@gmail.com |
Owner |
Sigourney |
Keokuk |
Iowa |
Darren Diethelm |
Myles Miller |
Signed |
9 |
2019-12-16 11:33 |
Anonymous (not verified) |
50.81.115.85 |
Travis Garrett and Caleb Elliott |
Partnership |
P.O. Box 55, Boone, IA 50036 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-16 |
Travis Garrett |
onethird4599@gmail.com |
Boone |
Boone |
IA |
Katie Frame |
Jessica Carroll |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Garrett & Caleb Elliott |
onethird4599@gmail.com |
Owner |
Boone |
Boone |
IA |
Katie Frame |
Jessica Carroll |
Signed |
10 |
2019-12-16 11:35 |
Anonymous (not verified) |
50.81.115.85 |
Travis Garrett and Caleb Elliott |
Partnership |
P.O. Box 55, Boone, IA 50036 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-16 |
Caleb Elliott |
onethird4599@gmail.com |
Boone |
Boone |
IA |
Katie Frame |
Jessica Carroll |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Garrett & Caleb Elliott |
onethird4599@gmail.com |
Owner |
Boone |
Boone |
IA |
Katie Frame |
Jessica Carroll |
Signed |
11 |
2019-12-17 19:46 |
Anonymous (not verified) |
50.83.188.192 |
B & B Construction |
Proprietorship |
2463 93rd Avenue, Norwalk, IA 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-17 |
Louis I. Maxwell |
brockbrooke2463@yahoo.com |
Norwalk |
IA |
United States |
Hope Winegardner |
Yvonne Ginther |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Louis Maxwell |
brockbrooke2463@yahoo.com |
Owner |
Norwalk |
IA |
United States |
Hope Winegardner |
Yvonne Ginther |
Signed |
12 |
2019-12-17 19:54 |
Anonymous (not verified) |
50.83.188.192 |
B & B Construction |
Proprietorship |
2463 93rd Avenue Norwalk, IA 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-17 |
Brock A Maxwell |
brock246393@gmail.com |
Des Moines |
IA |
United States |
Hope Winegardner |
Yvonne Ginther |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brock A Maxwell |
brock246393@gmail.com |
Owner |
Des Moines |
POlK |
Iowa |
Yvonne Ginther |
Hope Winegardner |
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 |
19 |
2019-12-31 16:29 |
Anonymous (not verified) |
172.58.83.45 |
A.M. Tile |
Proprietorship |
3824 122nd 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. |
2019-12-31 |
Amar Music |
amarmusic01@gmail.com |
Urbandale |
IA |
United States |
Sefik Music |
Amara Crncevic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Amar Music |
amarmusic01@gmail.com |
Owner |
Urbandale |
IA |
United States |
Sefik Music |
Amara Crncevic |
Signed |
20 |
2019-12-31 16:36 |
Anonymous (not verified) |
172.58.83.45 |
A.M. Tile |
Proprietorship |
3824 122nd 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. |
2019-12-31 |
Amar Music |
amarmusic01@gmail.com |
Urbandale |
IA |
United States |
Sefik Music |
Amara Crncevic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Omer Okic |
ultimate.exteriors@gmail.com |
Owner |
Des Moines |
Polk |
IA |
Sefik Music |
Amara Crncevic |
Signed |
22 |
2020-01-02 14:52 |
Anonymous (not verified) |
173.17.129.166 |
Dan & Sarah Gudenkauf |
Proprietorship |
3277 180th Ave, Ryan, IA 52330 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-02 |
Sarah Gudenkauf |
dandselectricmotor@gmail.com |
Ryan |
Delaware |
Iowa |
Nicole Almburg |
Kevin Corn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sarah Gudenkauf |
dandselectricmotor@gmail.com |
Owner |
Ryan |
Delaware |
Iowa |
Nicole Almburg |
Kevin Corn |
Signed |
23 |
2020-01-02 14:54 |
Anonymous (not verified) |
173.17.129.166 |
Dan Gudenkauf |
Proprietorship |
3277 180th Ave, Ryan, IA 52330 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-02 |
Dan Gudenkauf |
dandselectricmotor@gmail.com |
Ryan |
Delaware |
Iowa |
Nicole Almburg |
Kevin Corn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dan Gudenkauf |
dandselectricmotor@gmail.com |
Owner |
Ryan |
Delaware |
Iowa |
Nicole Almburg |
Kevin Corn |
Signed |
26 |
2020-01-04 17:23 |
Anonymous (not verified) |
45.53.67.52 |
Gary De Jager |
Limited Liability Company |
417 florida Ave NW Orange City Iowa 51041 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-04 |
Gary Dean De Jager |
mightyspear60@yahoo.com |
Orange City |
Souix |
Iowa |
Brody Dean De Jager |
Tyler Ray De Jager |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gary Dean De Jager |
mightyspear60@yahoo.com |
owner |
Orange City |
souix |
Iowa |
Brody Dean De Jager |
Tyler Ray De Jager |
Signed |
27 |
2020-01-06 09:17 |
Anonymous (not verified) |
24.149.10.119 |
Miss Wonderful LLC |
Limited Liability Company |
216 Main St Cedar Falls, IA 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-06 |
Ann Eastman |
misswonderful216@gmail.com |
Cedar Falls |
Black Hawk |
IA |
Rachel Lee |
Ann Remmert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ann Eastman |
misswonderful216@gmail.com |
Owner |
Cedar Falls |
Black Hawk |
IA |
Rachel Lee |
Ann Remmert |
Signed |
28 |
2020-01-06 13:39 |
Anonymous (not verified) |
108.178.203.226 |
MULLIS CATTLE LLC |
Limited Liability Company |
2506 155TH ST, EARLVILLE IA 52041 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-06 |
NICOLAS MULLIS |
JAMES@CIOIA.COM |
GREELEY |
DELAWARE |
IOWA |
MERRI MOSER |
BRITTANY LANSING |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
NICOLAS MULLIS |
JAMES@CIOIA.COM |
OWNER |
GREELEY |
DELAWARE |
IA |
MERRI MOSER |
BRITTANY LANSING |
Signed |
29 |
2020-01-06 13:44 |
Anonymous (not verified) |
108.178.203.226 |
MULLIS CATTLE LLC |
Limited Liability Company |
2506 155TH ST, EARLVILLE IA 52041 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-06 |
DAVID MULLIS |
JAMES@CIOIA.COM |
EARLVILLE |
DELAWARE |
IOWA |
MERRI MOSER |
BRITTANY LANSING |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
DAVID MULLIS |
JAMES@CIOIA.COM |
OWNER |
EARLVILLE |
DELAWARE |
IOWA |
MERRI MOSER |
BRITTANY LANSING |
Signed |
32 |
2020-01-08 08:31 |
Anonymous (not verified) |
199.120.118.90 |
BOBCATS LLC |
Limited Liability Company |
1860 505TH ST LINN GROVE 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. |
2019-11-18 |
CHRIS AXDAHL |
CHRISAXDAHLINC@HOTMAIL.COM |
LINN GROVE |
CLAY |
IOWA |
TESSA L STEFFEN |
JOSEPH E ZENKOVICH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
CHRIS AXDAHL |
CHRISAXDAHLINC@HOTMAIL.COM |
OWNER |
LINN GROVE |
CLAY |
IOWA |
TESSA L STEFFEN |
JOSEPH E ZENKOVICH |
Signed |
41 |
2020-01-20 14:26 |
Anonymous (not verified) |
173.24.181.211 |
BARBARA HOOGEVEEN |
Proprietorship |
304 MILL POND RD, ROCK RAPIDS, IA 51246 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-20 |
BARBARA HOOGEVEEN |
MCGILLH@MTCNET.NET |
ROCK RAPIDS |
LYON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
BARABARA HOOGEVEEN |
MCGILLH@MTCNET.NET |
OWNER |
ROCK RAPIDS |
LYON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
42 |
2020-01-24 12:26 |
Anonymous (not verified) |
173.24.181.211 |
MIKE EDDY |
Proprietorship |
PO BOX 437 OKOBOJI, IA 51355 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-22 |
MIKE EDDY |
joel@walkerinsuranceia.com |
OKOBOJI |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MIKE EDDY |
JOEL@WALKERINSURANCEIA.COM |
OWNER |
OKOBOJI |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
44 |
2020-01-28 12:55 |
Anonymous (not verified) |
173.24.181.211 |
AMANDA FIEDLER |
Proprietorship |
10 5TH AVE NW FOSTORIA, IA 51340 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-28 |
AMANDA FIEDLER |
JOEL@WALKERINSURANCEIA.COM |
FOSTORIA |
CLAY |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
AMANDA FIEDLER |
JOEL@WALKERINSURANCEIA.COM |
OWNER |
FOSTORIA |
CLAY |
IA |
JOSPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
60 |
2020-02-12 10:10 |
Anonymous (not verified) |
198.167.182.164 |
Sara Torres |
Proprietorship |
419 Lilac St, Tiffin, IA 52340 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-11 |
Sara Torres |
skb_blue08@hotmail.com |
Tiffin |
Johnson |
Iowa |
Steven J Fishman |
E. Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sara Torres |
skb_blue08@hotmail.com |
Owner |
Tiffin |
Johnson |
Iowa |
Steven J Fishman |
E Dyan Kriener |
Signed |
62 |
2020-02-17 06:55 |
Anonymous (not verified) |
173.31.111.29 |
Pa's Construction LLC |
Limited Liability Company |
2350 Glass Rd NE, Cedar Rapids, IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-17 |
Gregory Daniel Saunders |
gsaunders.pas@gmail.com |
CEDAR RAPIDS |
IOWA |
United States |
Laura Sturm |
Chad Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Saunders |
dan2112411@yahoo.com |
Owner |
Cedar Rapids |
Linn |
Iowa |
Walt Cheney |
Mike Broghammer |
Signed |
68 |
2020-02-19 12:00 |
Anonymous (not verified) |
198.14.241.59 |
SIERRA ROOFING LLC |
Limited Liability Company |
909 N ELM ST WEST LIBERTY IA 52776 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-19 |
ABRAHAM GRANJENO |
SIERRA89@GMAIL.COM |
WEST LIBERTY |
MUSCATINE |
IOWA |
JOSE SALGADO |
ALEJANDRIA FRAUSTO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
ABRAHAM GANJENO |
SIERRA89@GMAIL.COM |
OWNER |
WEST LIBERTY |
MUSCATINE |
IOWA |
JOSE SALGADO |
ALEJANDRIA FRAUSTO |
Signed |
69 |
2020-02-19 15:58 |
Anonymous (not verified) |
198.14.241.59 |
MORENOS C ROOFING LLC |
Limited Liability Company |
2018 WATERFRONT DR LOT 73 IOWA CITY IA 52240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-19 |
RAQUEL OLEA CAMACHO |
JORGETREJO19896@GMAIL.COM |
IOWA CITY |
JOHNSON |
IOWA |
JORGE TREJO |
JOSE SALGADO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RAQUEL OLEA CAMACHO |
JORGETREJO19896@GMAIL.COM |
OWNER |
IOWA CITY |
JOHNSON |
IOWA |
JORGE TREJO |
JOSE SALGADO |
Signed |
83 |
2020-02-28 12:55 |
Anonymous (not verified) |
204.16.58.27 |
Baltes Trucking LLC |
Limited Liability Company |
203 N Gilmore Ave New Hampton IA 50659 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-28 |
Clinton Lee Baltes |
clintbaltes@gmail.com |
New Hampton |
Chickasaw |
Iowa |
Tammy Robinson |
Richard Kramer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Clinton Lee Baltes |
clintbaltes@outlook.com |
Owner |
New Hampton |
Chickasaw |
Iowa |
Tammy Robinson |
Richard Kramer |
Signed |
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 |
95 |
2020-03-18 14:47 |
Anonymous (not verified) |
173.24.186.251 |
Layton C. Vick II dba Layton's Backhoe Service |
Proprietorship |
PO Box 652 / 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. |
2020-03-18 |
Layton Clarence VIck II |
lcvii2@gmail.com |
Lake Park |
Dickinson |
Iowa |
Daniel Reimers |
Marcus VanKleek |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Layton C. Vick II |
lcvii2@gmail.com |
Owner |
Lake Park |
Dickinson |
Iowa |
Daniel Reimers |
Marcus VanKleek |
Signed |
97 |
2020-03-21 12:05 |
Anonymous (not verified) |
173.22.82.137 |
JHK Construction LLC |
Limited Liability Company |
6203 Casey Court NE 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. |
2020-03-21 |
Edward Charles Loehr |
jhkconstruction10@gmail.com |
Cedar Rapids |
Linn County |
Iowa |
Brandon Peters |
Mandy Mason |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Edward Charles Loehr |
jhkconstruction10@gmail.com |
Owner |
6203 Casey Court NE |
Linn County |
Iowa |
Brandon Peters |
Mandy Mason |
Signed |
101 |
2020-03-24 15:49 |
Anonymous (not verified) |
161.69.123.10 |
Blair Lincoln |
Proprietorship |
32586 390th St Colesburg, IA 52035 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-24 |
Blair Alan Lincoln |
balincoln@gmail.com |
Colesburg |
County |
Iowa |
Brandon Mather |
Travis Ries |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Blair Alan Lincoln |
balincoln@gmail.com |
Owner |
Colesburg |
County |
IA |
Brandon Mather |
Travis Ries |
Signed |
104 |
2020-03-26 19:00 |
Anonymous (not verified) |
173.189.167.170 |
MCB CONSTRUCTION INC |
Limited Liability Company |
3484 VERMONT ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-26 |
michael wade bethards |
mwbethards@yahoo.com |
NEW VIRGINIA |
IA |
IA |
noel isaac |
alice lohmann |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
mike bethards |
mwbethards@yahoo.com |
owner |
New Virginia |
warren |
IA |
noel isaac |
alice lohmann |
Signed |
109 |
2020-04-03 12:42 |
Anonymous (not verified) |
174.219.131.25 |
Upright Construction |
Limited Liability Company |
2514 S norton 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. |
2020-04-03 |
Maurice Williams |
uprightway@mail.com |
Sioux Falls |
Minihaha |
SD |
Ashley Williams |
Chris Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maurice Williams |
uprightway@mail.com |
Owner |
Sioux Falls |
Minihaha |
SD |
Ashley Williams |
Chris Johnson |
Signed |
110 |
2020-04-06 14:13 |
Anonymous (not verified) |
99.203.98.177 |
Stifel seasonal services |
Limited Liability Company |
935 4th street waukee |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-06 |
Dalton Stifel |
daltonstifel@icloud.com |
waukee |
Dallas |
IA |
Bryant ternes |
Tammy stifel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dalton Stifel |
daltonstifel@icloud.com |
Owner |
waukee |
Dallas |
IA |
Bryant Ternes |
Tammy Stifel |
Signed |
112 |
2020-04-07 12:16 |
Anonymous (not verified) |
173.27.33.108 |
Josh Alley Siding |
Proprietorship |
205 N Oak St. Davis City, IA 50065 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2018-04-10 |
Joshua H. Alley |
alley.josh@yahoo.com |
Davis City |
Decatur |
Iowa |
Joe Fitzgerald |
Steve Young |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Alley Siding |
alley.josh@yahoo.com |
Owner |
Davis City |
Decatur |
Iowa |
Joe Fitzgerald |
Steve Young |
Signed |
113 |
2020-04-07 12:30 |
Anonymous (not verified) |
173.27.33.108 |
Aarron Alley |
Proprietorship |
101 S Teale 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. |
2018-05-15 |
Aarron Alley |
aarronalley10@yahoo.com |
Davis City |
Decatur |
Iowa |
Joe Fitzgerald |
Steve Young |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aarron Alley |
aarronalley10@yahoo.com |
Owner |
Davis City |
Decatur |
Iowa |
Joe Fitzgerald |
Steve Young |
Signed |
114 |
2020-04-08 10:51 |
Anonymous (not verified) |
167.142.107.216 |
1959 |
Proprietorship |
601 Country Club Rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-23 |
Timothy Alan Pottebaum |
tpottebaum@nethtc.net |
SHELDON |
O'Brien |
Iowa |
Jill Boerta |
Kris Schoo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy Alan Pottebaum |
tpottebaum@nethtc.net |
owner |
SHELDON |
O'brien |
Iowa |
Jill Boerta |
Kris Schoo |
Signed |
115 |
2020-04-09 11:42 |
Anonymous (not verified) |
67.60.46.104 |
D&H Plumbing, L.L.C |
Limited Liability Company |
44214 260th St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-05 |
Delwayne Merrill Abbott |
del_abbott@yahoo.com |
Kingsley |
Plymouth |
Iowa |
Doug Alan Gerdes |
Nick William Lahrs |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Delwayne Merrill Abbott |
brettherbold@gmail.com |
Owner |
Kingsley |
Plymouth |
Iowa |
Doug Alan Gerdes |
Nick William Lahrs |
Signed |
116 |
2020-04-09 11:45 |
Anonymous (not verified) |
67.60.46.104 |
D&H Plumbing, L.L.C |
Limited Liability Company |
44214 260th St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-05 |
Brett Alan Herbold |
brettherbold@gmail.com |
Remsen |
Plymouth |
Iowa |
Doug Alan Gerdes |
Nick Willam Lahrs |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Delwayne Merrill Abbott |
brettherbold@gmail.com |
Owner |
Kinglsey |
Plymouth |
Iowa |
Doug Alan Gerdes |
Nick William Lahrs |
Signed |
127 |
2020-04-24 09:18 |
Anonymous (not verified) |
63.152.82.5 |
TD Auto Services LLC |
Limited Liability Company |
451 W Parker St 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. |
2020-01-27 |
Dakoda Sellers |
dakoda.d.sellers@gmail.com |
Waverly |
Bremer |
IA |
Jennie Roster |
Dustin Roster |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dakoda D Sellers |
dakoda.d.sellers@gmail.com |
Owner |
Waverly |
Bremer |
IA |
Jennie Roster |
Dustin Roster |
Signed |
135 |
2020-04-28 10:04 |
Anonymous (not verified) |
74.84.101.138 |
W.A.D.E., Inc. DBA Decorah Cleaners |
Proprietorship |
504 Heivly Street 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. |
2020-01-23 |
Darrin Walter |
chelsea.whalen@upperiowains.com |
Decorah |
Winneshiek |
IA |
Robin C Schultz |
Chelsea Whalen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Darrin Walter |
chelsea.whalen@upperiowains.com |
Owner |
Decorah |
Winneshiek |
IA |
Robin C Schultz |
Chelsea Whalen |
Signed |
136 |
2020-04-28 10:06 |
Anonymous (not verified) |
74.84.101.138 |
W. A. D. E., Inc. DBA Decorah Cleaners |
Proprietorship |
504 Heivly Street 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. |
2020-01-23 |
Wanda Walter |
chelsea.whalen@upperiowains.com |
Decorah |
Winneshiek |
IA |
Robin C Schultz |
Chelsea Whalen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wanda Walter |
chelsea.whalen@upperiowains.com |
Owner |
Decorah |
Winneshiek |
IA |
Robin C Schultz |
Chelsea Whalen |
Signed |
150 |
2020-05-06 10:59 |
Anonymous (not verified) |
76.190.229.163 |
RNR Holdings LLC |
Limited Liability Company |
4330 Winter Eagle Trail SE Apt B, Iowa City, Iowa 52240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-06 |
Richard E. White |
rwhite245@yahoo.com |
Hermitage |
Mercer |
Pennsylvania |
Gene Bell |
Victor J Veltri |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Richard E White |
rwhite245@yahoo.com |
Owner |
Hermitage |
Mercer |
Pennsylvania |
Gene Bell |
Victor J Veltri |
Signed |
153 |
2020-05-12 12:58 |
Anonymous (not verified) |
172.58.86.150 |
Big Head Burger |
Limited Liability Company |
706 Quincy st. Waterloo, Iowa 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. |
2020-05-12 |
David Westley Bryant |
questions.bhb@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Darlean Crawford |
Everlue Kincaid |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Westley Bryant |
questions.bhb@gmail.com |
Owner |
Waterloo |
Black Hawk |
Iowa |
Darlean Crawford |
Everlue Kincaid |
Signed |
158 |
2020-05-18 13:58 |
Anonymous (not verified) |
108.59.100.21 |
LNM Truck & Trailer Repair LLC |
Limited Liability Company |
902 Rossville Rd, Waukon, IA 52172 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2020-05-18 |
Matthew Hawkins |
lnmtruckandtrailerrepair@gmail.com |
Waterville |
Allamakee |
IA |
Jane M Regan |
Chelsea Whalen |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Matthew Hawkins |
lnmtruckandtrailerrepair@gmail.com |
Owner |
Waterville |
Allamakee |
IA |
Jane M Regan |
Chelsea Whalen |
Signed |
161 |
2020-05-19 11:31 |
Anonymous (not verified) |
208.95.1.97 |
Paul McCoy DBA McCoy Contracting |
Proprietorship |
2806 Highway T47, Montour, Iowa 50173 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-19 |
Paul McCoy |
paulrmccoy1969@gmail.com |
Montour |
Tama |
Iowa |
Mike Thede |
Toni Chaska |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paul McCoy |
paulrmccoy1969@gmail.com |
Owner |
Montour |
Tama |
Iowa |
Mike Thede |
Toni Chaska |
Signed |
165 |
2020-05-26 14:12 |
Anonymous (not verified) |
216.51.228.161 |
Arbor Way All About Trees |
Limited Liability Company |
417 Howard 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. |
2021-05-26 |
Nicholas Plumski |
arborway14@gmail.com |
Saint Anthony |
Marshall |
Iowa |
Michael Richards |
Nicole Plumski |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas Plumski |
arborway14@gmail.com |
Owner |
St. Anthony |
Marshall |
IA |
Michael Richards |
Nicole Plumski |
Signed |
190 |
2020-06-19 11:08 |
Anonymous (not verified) |
107.77.207.128 |
PAT Construction |
Limited Liability Company |
6007 Sw 15th ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-21 |
Pablo Aguilar Tolentino |
PATConstruction77@gmail.com |
DES MOINES |
77 |
77 |
Trisha Resendiz |
Toni Lopez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Pablo Aguilar Tolentino |
PATconstruction77@gamil.com |
owner |
DES MOINES |
77 |
77 |
Trisha Resendiz |
Toni Lopez |
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 |
207 |
2020-07-16 13:05 |
Anonymous (not verified) |
173.16.140.254 |
Steve Kennedy |
Proprietorship |
5108 SW 13th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-16 |
Steve Kennedy |
stevekennedy@gmail.com |
Des Moines |
Polk |
Iowa |
Jen Echterling |
Jake Hibbert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steve Kennedy |
stevekennedy007@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Jen Echterling |
Jake Hibbert |
Signed |
210 |
2020-07-20 13:28 |
Anonymous (not verified) |
75.162.95.97 |
RM construction |
Proprietorship |
65 SE 5TH STREET APT 4 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. |
2020-07-20 |
Rafael Marquez |
marquezrafael1@outlook.com |
Des Moines |
Polk IOWA |
IOWA |
Richard Yanez |
Francisco Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rafael Marquez |
marquezrafael1@outlook.com |
owner |
Des Moines |
Polk |
IOWA |
Richard Yanez |
Francisco Garcia |
Signed |
220 |
2020-08-02 13:45 |
Anonymous (not verified) |
99.203.112.113 |
R&G SEAMLESS GUTTERS |
Proprietorship |
3244 Dubuque Ave, 3244 Dubuque 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. |
2020-08-02 |
Ruben Munoz Haro |
munozharoruben@gmail.com |
Des Moines |
Polk |
Estados Unidos |
Gabriel Ramirez |
Adriana Ramirez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ruben Munoz- R&G SEAMLESS GUTTERS |
Munozharoruben@gmail.com |
owner |
3244 Dubuque Ave Des Moines Iowa 50317 |
polk |
iowa |
Gabriel Ramirez |
Adriana Ramirez |
Signed |
221 |
2020-08-03 12:03 |
Anonymous (not verified) |
167.142.196.238 |
Israel Moreno |
Proprietorship |
Po Box 186 Williams, IA 50271 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-12 |
Israel Moreno |
mikjuniormoreno@hotmail.com |
Williams |
Hamilton |
Iowa |
Justin J Malloy |
Myndi Grimsley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Israel Moreno |
mikjuniormoreno@hotmail.com |
owner |
Williams |
Hamilton |
Iowa |
Justin J Malloy |
Myndi Grimsley |
Signed |
233 |
2020-08-17 14:24 |
Anonymous (not verified) |
165.225.0.98 |
Daniel L Knebel |
Proprietorship |
439 Carroll Blvd, Dunkerton, IA, 50626 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-17 |
Daniel L Knebel |
knebeldan@gmail.com |
Dunkerton |
Black Hawk |
Iowa |
Carman M Knebel |
Joseph E Knebel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel L Knebel |
knebeldan@gmail.com |
Owner |
Dunkerton |
Black Hawk |
Iowa |
Carman M Knebel |
Joseph E Knebel |
Signed |
235 |
2020-08-18 13:25 |
Anonymous (not verified) |
50.83.91.36 |
Tyler Abigt |
Proprietorship |
636 Crestview Ave Ottumwa, 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. |
2020-08-18 |
Tyler Abigt |
Abigtlettering@gmail.com |
Ottumwa |
Wapello |
Iowa |
Jonathan Strube |
Michelle Abigt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tyler Abigt |
Abigtlettering@gmail.com |
Owner |
Ottumwa |
Wapello |
Iowa |
Jonathan Strube |
Michelle Abigt |
Signed |
238 |
2020-08-19 13:13 |
Anonymous (not verified) |
107.77.199.95 |
Southern Ag Care |
Limited Liability Company |
301 Hoover Dr |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-19 |
Southern Ag Care |
russ_buntyn@yahoo.com |
Monroe |
Ouachita |
LA |
Mark Buntyn |
Johna Buntyn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Russell Buntyn |
russ_buntyn@yahoo.com |
Owner |
Monroe |
Ouachita |
LA |
Mark Buntyn |
Johna Buntyn |
Signed |
242 |
2020-08-24 09:27 |
Anonymous (not verified) |
159.242.43.24 |
Bontreger Seamless Gutters |
Proprietorship |
501 S Center St. Zearing Ia 50278 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-24 |
Harvey Bontreger |
borntrgerharvey@gmail.com |
Zearing |
Story |
Ia |
Alex G Meier |
Daniel Wunschel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Harvey Bontreger |
borntrgerharvey@gmail.com |
Owner |
Zearing |
Story |
Ia |
Alex G Meier |
Daniel Wunschel |
Signed |
243 |
2020-08-24 11:31 |
Anonymous (not verified) |
159.242.43.24 |
Borntreger Seamless Gutters |
Proprietorship |
501 S Center St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-24 |
Harvey Borntrager |
Borntregerharvey@gmail.com |
Zearing |
Story |
Ia |
Alex G Meier |
Daniel Wunschel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Harvey Borntreger |
borntregerharvey@gmail.com |
Owner |
Zearing |
Story |
Ia |
Alex Meier |
Daniel Wunschel |
Signed |
245 |
2020-08-25 15:20 |
Anonymous (not verified) |
107.77.207.111 |
J&R cleaning co LLC |
Limited Liability Company |
14300 Holcomb ave #210 urbandale ia. 50323 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-25 |
José A salas romero |
chinito80sr@hotmail.com |
Desmoines |
Polk |
Iowa |
Ana López |
Jesus gonzales |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
José romero |
chinito80sr@hotmail.com |
Owner |
Desmoines |
Polk |
Iowa |
Ana lopez |
Jesus Gonzales |
Signed |
251 |
2020-09-08 17:00 |
Anonymous (not verified) |
173.27.45.95 |
Peerless Construction, LLC |
Limited Liability Company |
4718 E 49th 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. |
2020-09-08 |
Grant Jipp |
grant.peerless@gmail.com |
Davenport |
Scott |
Iowa |
Dan Knight |
Bridget Knight |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Grant Jipp |
grant.peerless@gmail.com |
Owner |
Davenport |
Scott |
Iowa |
Dan Knight |
Bridget Knight |
Signed |
253 |
2020-09-09 12:27 |
Anonymous (not verified) |
173.18.16.129 |
H E Drywall INC |
Proprietorship |
200 E Lally St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-09 |
Eriberto Castro |
hedrywall82@gmail.com |
Des Moines |
Polk |
Iowa |
Lesa Reeves |
Jake Hibbert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
eriberto castro |
hedrywall82@gmail.com |
owner |
Des Moines |
Polk |
Iowa |
Lesa Reeves |
Jake Hibbert |
Signed |
264 |
2020-09-21 13:26 |
Anonymous (not verified) |
107.77.173.3 |
JAG Painting |
Proprietorship |
1423 Des Moines Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-21 |
Berenice S Silva |
berenicesssvaldes@gmail.com |
Des Moines |
Polk |
Iowa |
Luis Garcia |
Maria Salas |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Berenice S Silva |
berenicesssvaldes@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Luis Garcia |
Maria Salas |
Signed |
268 |
2020-09-22 09:21 |
Anonymous (not verified) |
174.217.16.178 |
Ayala Brothers Painting & Drywall |
Proprietorship |
25089 H Ave Adel IA 50003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-22 |
Edson Ayala Arizaga |
Ayalabrospainting@gmail.com |
Adel |
Dallas |
Iowa |
Abel Ayala |
Laura Orozco |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Edson Ayala Arizaga |
Edsonayala.12@gmail.com |
Owner |
Adel |
Dallas |
Iowa |
Abel Ayala |
Laura Orozco |
Signed |
273 |
2020-10-05 13:57 |
Anonymous (not verified) |
173.30.54.139 |
Jackson Exteriors |
Proprietorship |
705 Cherry Avenue Woodward,ia 50276 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-05 |
Lucas Jackson |
ljajackson41977@gmail.com |
Woodward |
IA |
United States |
Cody Roth |
Dustin Perry |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lucas Jackson |
ljajackson41977@gmail.com |
Owner |
Woodward |
Dallas |
United States |
Cody Roth |
Dustin perry |
Signed |
274 |
2020-10-06 13:18 |
Anonymous (not verified) |
174.250.65.147 |
Ddp construction |
Proprietorship |
1923 63rd st. 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. |
2020-10-06 |
Dustin a perry |
perrythedustin@gmail.com |
Urbandale |
Polk |
Iowa |
Luke jackson |
Loud jackson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin perry |
perrythedustin@gmail.com |
Owner |
Urbandale |
Polk |
Iowa |
Luke jackson |
Loyd jackson |
Signed |
277 |
2020-10-08 14:21 |
Anonymous (not verified) |
173.18.16.129 |
Mb Construction and Real Estate LLC |
Limited Liability Company |
5375 Katelyn Ave 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. |
2020-10-08 |
Michael Mohr |
mike@mohrhomesia.com |
Van Meter |
Dallas |
Iowa |
Lesa Reeves |
Samantha Hartley-Bullen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MB Construction and Real Estate LLC |
mike@mohrhomesia.com |
Owner |
Van Meter |
Dallas |
Iowa |
Lesa Reeves |
Samantha Hartley-Bullen |
Signed |
283 |
2020-10-21 09:19 |
Anonymous (not verified) |
192.16.108.199 |
Blazin Homes |
Proprietorship |
2306 Hill St Denison Iowa 51442 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-21 |
Chad David Blasey |
chadblasey@yahoo.com |
Denison |
Crawford |
Iowa |
Amy Hansen |
Todd Stadtlander |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chad David Blasey |
chadblasey@yahoo.com |
Owner |
Dension |
Crawford |
Iowa |
Amy Hansen |
Todd Stadtlander |
Signed |
284 |
2020-10-21 12:52 |
Anonymous (not verified) |
207.177.50.27 |
Luke Croghan |
Proprietorship |
2404 2200th street ,Manilla Ia. 51454 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-21 |
luke F Croghan |
croghanluke@gmail.com |
manilla |
Shelby |
Iowa |
Amy Hansen |
Todd Stadlander |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
luke F Croghan |
croghanluke@gmail.com |
Owner |
manilla |
Shelby |
Iowa |
Amy Hansen |
Todd Stadlander |
Signed |
286 |
2020-10-21 18:32 |
Anonymous (not verified) |
173.218.73.44 |
Bilyeu Underground LLC |
Limited Liability Company |
1136 W. Irene Ct. Nixa, MO 65714 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-21 |
Daniel Bilyeu |
danielbilyeu@gmail.com |
Nixa |
Christian |
Missouri |
Gary George Bilyeu |
Chad Anthony Charles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Bilyeu |
danielbilyeu@gmail.com |
Owner |
Nixa |
Christian |
Missouri |
Gary George Bilyeu |
Chad Anthony Charles |
Signed |
287 |
2020-10-21 18:35 |
Anonymous (not verified) |
173.218.73.44 |
Bilyeu Underground LLC |
Limited Liability Company |
1136 W. Irene Ct. Nixa, MO 65714 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-21 |
Gary George Bilyeu |
garygb1990@gmail.com |
Sparta |
Christian |
Missouri |
Daniel Bilyeu |
Chad Anthony Charles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gary George Bilyeu |
garygb1990@gmail.com |
Owner |
Sparta |
Christian |
Missouri |
Chad Anthony Charles |
Daniel Bilyeu |
Signed |
288 |
2020-10-21 18:36 |
Anonymous (not verified) |
173.218.73.44 |
Bilyeu Underground LLC |
Limited Liability Company |
1136 W. Irene Ct. Nixa, MO 65714 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-21 |
Chad Anthony Charles |
y4ardgn0m3r@gmail.com |
Nixa |
Christian |
Missouri |
Gary George Bilyeu |
Daniel Bilyeu |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chad Anthony Charles |
y4ardgn0m3r@gmail.com |
Owner |
Nixa |
Christian |
Missouri |
Gary George Bilyeu |
Daniel Bilyeu |
Signed |
290 |
2020-10-23 15:13 |
Anonymous (not verified) |
74.42.24.42 |
Gunter Trucking LLC |
Limited Liability Company |
704 River Ave N., Belmond, IA 50421 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-23 |
Michael James Gunter |
mikegunter885@yahoo.com |
Belmond |
Wright |
Iowa |
Sondra Faye Godsell |
Lori Lynn Studer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael James Gunter |
mikegunter885@yahoo.com |
Owner |
Belmond |
Wright |
Iowa |
Sondra Faye Godsell |
Lori Lynn Studer |
Signed |
297 |
2020-10-30 10:43 |
Anonymous (not verified) |
216.51.132.207 |
Kregel Farm Partnership |
Limited Liability Partnership |
30392 Garber 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. |
2020-09-08 |
Travis Kregel |
TRAVIS.KREGEL@GMAIL.COM |
Garber |
Clayton |
Iowa |
Jerry J Rochford |
Nicole L Parker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Kregel |
TRAVIS.KREGEL@GMAIL.COM |
owner |
Guttenberg |
Clayton |
Iowa |
Jerry J Rochford |
Nicole L Parker |
Signed |
299 |
2020-10-30 10:47 |
Anonymous (not verified) |
216.51.132.207 |
Kregel Farm Partnership LLP |
Limited Liability Partnership |
30392 Garber 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. |
2020-09-09 |
Darlene Kregel |
TRAVIS.KREGEL@GMAIL.COM |
Guttenberg |
Clayton |
Iowa |
Jerry J Rochford |
Nicole L Parker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Darlene Kregel |
TRAVIS.KREGEL@GMAIL.COM |
owner |
Guttenberg |
Clayton |
Iowa |
Jerry J Rochford |
Nicole L Parker |
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 |
308 |
2020-11-08 09:17 |
Anonymous (not verified) |
173.27.33.108 |
Aarron Alley |
Proprietorship |
101 S Teale St. Davis City, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-11-01 |
Aarron Alley |
aarronalley10@yahoo.com |
Davis City |
Decatur |
Iowa |
Joe Fitzgerald |
Steve Young |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aarron Alley |
aarronalley10@yahoo.com |
Owner |
Davis City |
Decatur |
Iowa |
Joe Fitzgerald |
Steve Young |
Signed |
312 |
2020-11-11 18:12 |
Anonymous (not verified) |
173.16.216.53 |
Skb transportation llc |
Limited Liability Company |
401 6th street west amana iowa 52203 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-11 |
Scott Wayne bryant |
skbtransportation@icloud.com |
West amana |
Iowa |
Iowa |
Nichole prokop |
Cory prokop |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Scott Wayne bryant |
skbtransportation@icloud.com |
Owner |
West amana |
Iowa |
Iowa |
Nichole prokop |
Cory prokop |
Signed |
321 |
2020-11-17 10:26 |
Anonymous (not verified) |
173.18.16.129 |
Adam Quimby |
Proprietorship |
2033 10th 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. |
2020-11-01 |
Adam Quimby |
adam.m.quimby@gmail.com |
Des Moines |
Polk |
Iowa |
Robert Coluzzi |
Kelly Coluzzi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adam Quimby |
adam.m.quimby@gmail.com |
Owner |
Des Moines |
Polk |
Iow |
Robert Coluzzi |
Kelly Coluzzi |
Signed |
324 |
2020-11-20 09:08 |
Anonymous (not verified) |
71.39.227.238 |
County-Line Construction, LLC |
Limited Liability Company |
314 NE 2nd St, Panora, IA 50216 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-20 |
John Steve Vogel |
thevogels@netins.net |
Panora |
Guthrie |
Iowa |
Steve Phillips |
Abbey Luellen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Steve Vogel |
thevogels@netins.net |
Owner |
Panora |
Guthrie |
Iowa |
Steve Phillips |
Abbey Luellen |
Signed |
325 |
2020-11-23 11:14 |
Anonymous (not verified) |
174.198.82.169 |
Dan davidson |
Limited Liability Company |
21Lincoln Dr |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2020-11-22 |
Daniel Lee davidson |
unitedremodelingdd@gmail.com |
Palo |
Linn |
IA |
Daniel Lee davidson |
Daniel Lee davidson |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Daniel Lee davidson |
unitedremodelingdd@gmail.com |
Owner |
Palo |
Linn |
IA |
Daniel Lee davidson |
Daniel Lee davidson |
Signed |
330 |
2020-12-03 08:11 |
Anonymous (not verified) |
208.126.61.46 |
Hometown Comfort Heating & Cooling, LLC. |
Limited Liability Company |
1855 280th St. Webster City, Ia. 50595 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-03 |
Mason Ormesher |
hometowncomfortia@gmail.com |
Webster City |
IA |
United States |
Kylee Ormesher |
Karen Ostrem |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mason Ormesher |
hometowncomfortia@gmail.com |
Owner |
Webster City |
Hamilton |
Iowa |
Kylee Ormesher |
Karen Ostem |
Signed |
335 |
2020-12-08 11:08 |
Anonymous (not verified) |
173.18.16.129 |
quintanillas construction llc |
Limited Liability Company |
3136 6th ave 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. |
2020-12-08 |
maynor quintanilla |
maynorquintanilla42@gmail.com |
des moines |
polk |
Iowa |
Lesa Reeves |
Jen Lambert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
maynor quintanilla |
maynorquintanilla42@gmail.com |
owner |
des moines |
polk |
Iowa |
Lesa Reeves |
Jen Lambert |
Signed |
336 |
2020-12-11 11:55 |
Anonymous (not verified) |
173.16.197.72 |
A Metro Snow Removal And Lawn Care |
Limited Liability Company |
6436 Washington Ave Windsor Heights, Iowa 50324 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-11 |
Jeff Lamp Sr. |
jeff.lamp79@gmail.com |
Windsor Height |
Polk |
Iowa |
Rick Brown |
Jill Fresh |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeff Lamp Sr. |
Jeff.lamp79@gmail.com |
Owner |
Windsor Heights |
Polk |
Iowa |
Rick Brown |
Jill Fresh |
Signed |