579 |
2021-07-20 12:37 |
Anonymous (not verified) |
166.205.124.133 |
M&M HOME IMPROVEMENT |
Limited Liability Company |
5406 28th Ave. Moline , IL 61265 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2021-07-20 |
Jarred Alexander |
bookkyddjay@gmail.com |
Moline |
USA |
IL |
Jacob Nagel |
Jacob Nagel |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jarred Alexander |
bookkyddjay@gmail.com |
Same |
Moline |
USA |
IL |
Jacob Nagel |
Jacob Nagel |
Signed |
646 |
2021-09-20 08:54 |
Anonymous (not verified) |
173.24.107.209 |
QCA Professional Contractors |
Limited Liability Company |
3314 67th Ave, Moline, IL. 61265 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-20 |
Allan Celada |
allancelada@qcaprocontractors.com |
Moline |
Rock Island |
IL |
Alexander Celada |
Drexel Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Allan Celada |
allancelada@qcaprocontractors.com |
self |
Moline |
Rock Island |
IL |
Alexander Celada |
Drexel Miller |
Signed |
674 |
2021-10-15 09:43 |
Anonymous (not verified) |
173.29.63.3 |
Peter Hawley |
Proprietorship |
524 n galena ave, Wyoming Illinois 61491 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-15 |
Peter Anthony Hawley |
hawleypete801@gmail.com |
Wyoming |
Stark |
Illinois |
Elizabeth Doreen Hawley |
Ian Matthew Esmoil |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Peter Anthony Hawley |
hawleypete801@gmail.com |
Self |
Wyoming |
Stark |
IL |
Elizabeth Doreen Hawley |
Ian Matthew Esmoil |
Signed |
734 |
2021-11-11 14:05 |
Anonymous (not verified) |
72.13.16.172 |
REDFEARN TRUCKING INC |
Proprietorship |
5512 WEST STAGECOACH TRAIL |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
REDFEARN TRUCKING INC |
dave@allseasonstrucking.com |
GALENA |
JODAVIES |
IL |
DAVE NEUWOHNER |
BEN MOYER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
REDFEARN TRUCKING INC |
dave@allseasonstrucking.com |
PRESIDENT |
GALENA |
JODAVIES |
IL |
DAVE NEUWOHNER |
BEN MOYER |
Signed |
751 |
2021-11-16 15:51 |
Anonymous (not verified) |
166.181.83.87 |
Dylan Wilson SMS & More |
Proprietorship |
7500 25th Milan IL 61264 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-16 |
Dylan Wilson |
doe33843@gmail.com |
Milan |
Rock Island |
IL |
Jamie Short |
Brett Dawson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jennifer Groech |
wilsoncrazy@gmail.com |
Grandmother |
Moline |
Rock Island |
IL |
Jamie Short |
Brett Dawson |
Signed |
761 |
2021-11-22 07:22 |
Anonymous (not verified) |
73.211.163.27 |
James crockett |
Limited Liability Company |
417 easr st south Kewanee il 61443 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-22 |
James crockett |
tattoojec@gmail.com |
Kewanee il |
Henery |
Il |
Tom mcintire |
Colton english |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Hog city construction |
tattoojec@gmail.com |
Self |
Kewanee |
Henery |
Il |
Tom mcintire |
Colon english |
Signed |
1575 |
2023-04-16 09:00 |
Anonymous (not verified) |
94.188.205.176 |
Velocity Improvement, LLC |
Proprietorship |
PO Box 903, Wilton IA 52778 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-16 |
Kent Grunhovd |
velocityimprovement@gmail.com |
Wilton |
Scott |
Iowa |
Robin Throne |
LaVonne Grunhovd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kent Grunhovd |
kgrunhovd3535@gmail.com |
Self |
Bloomington |
McLean |
IL |
Robin Throne |
LaVonne Grunhovd |
Signed |
1830 |
2023-09-08 11:45 |
Anonymous (not verified) |
94.188.205.177 |
Bradley A Sneeden |
Proprietorship |
36 Sunset Drive, Beardstown, IL 62618 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Bradley A Sneeden |
bradsneeden@gmail.com |
Beardstown |
Cass |
IL |
Billie Sneeden |
Dillon McNeff |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bradley A Sneeden |
bradsneeden@gmail.com |
Self |
Beardstown |
Cass |
IL |
Billie Sneeden |
Dillon McNeff |
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 |
1871 |
2023-10-18 10:27 |
Anonymous (not verified) |
94.188.205.169 |
Derik Gonyier |
Proprietorship |
1421 Chicago Ave, Savanna, IL 61074 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-14 |
Derik Ray Gonyier |
deriknalexis121413@gmail.com |
Savanna |
Carroll |
IL |
Kyle Lee Sturtz |
Daryl Gonyier |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derik Ray Gonyier |
deriknalexis121413@gmail.com |
Self |
Savanna |
Carroll |
IL |
Kylee Lee |
Daryl Eugene Gonyier |
Signed |
1872 |
2023-10-18 10:59 |
Anonymous (not verified) |
94.188.205.177 |
Derik Gonyier |
Proprietorship |
1421 Chicago Ave, Savanna, IL 61074 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-14 |
Derik Ray Gonyier |
deriknalexis121413@gmail.com |
Savanna |
Carroll |
IL |
Kyle Lee Sturtz |
Daryl Eugene Gonyier |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derik Ray Gonyier |
deriknalexis121413@gmail.com |
Self |
Savanna |
Carroll |
IL |
Kyle Lee Sturtz |
Daryl Eugene Gonyier |
Signed |
1925 |
2023-11-28 09:44 |
Anonymous (not verified) |
94.188.207.224 |
Pietro Solutions |
Limited Liability Company |
719 11th Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-28 |
Ronaldo Di Pietro |
girodp@gmail.com |
Rock Island |
Rock Island |
IL |
Rita de Cássia Gallo |
Antonio Carlos Gallo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ronaldo Di Pietro |
girodp@gmail.com |
Self |
Rock Island |
Rock Island |
IL |
Rita de Cássia Gallo |
Antonio Carlos Gallo |
Signed |
1951 |
2023-12-12 13:10 |
Anonymous (not verified) |
94.188.207.230 |
Patrick McGuinnis |
Limited Liability Company |
5697 Squire Circle, Thomson, IL 61285 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-09 |
Patrick A McGinnis |
McGinnistrucking2023@yahoo.com |
Thomson |
Carroll |
IL |
Ashleigh McGuinnis |
Kimberly Williams |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Parick A McGunnis |
mcginnistrucking2023@yahoo.com |
Self |
Thomson |
Carroll |
IL |
Ashleigh McGinnis |
Kimberly Williams |
Signed |
1952 |
2023-12-12 13:26 |
Anonymous (not verified) |
94.188.205.167 |
Austin Albin |
Proprietorship |
2263 Railroad Street, Jacksonville, IL 62650 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-23 |
Austin R Albin |
albinaustin12@gmail.com |
Jacksonville |
Morgan |
IL |
Wayne Albin |
Jerry Roth |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Austin R Albin |
albinaustin12@gmail.com |
Self |
Jacksonville |
Morgan |
IL |
Wayne Albin |
Jerry Roth |
Signed |
2199 |
2024-05-03 13:27 |
Anonymous (not verified) |
94.188.207.228 |
Polar Delights LLC DBA Twists Ice Cream |
Limited Liability Company |
110 S 9th Ave Eldridge IA 52748 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-03 |
Anna Kokity |
amkokity@gmail.com |
Moline |
Rock Island |
IL |
Ashley Schwien |
Kasey Lange |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Anna Kokity |
amkokity@gmail.com |
self |
Moline |
Rock Island |
IL |
Ashley Schwien |
Kasey Lange |
Signed |
232 |
2020-08-16 11:28 |
Anonymous (not verified) |
173.27.57.39 |
Landeros & Sons Construction, Inc |
Limited Liability Partnership |
1636 19th Avenue |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-16 |
Fernando Landeros |
fland1983@gmail.com |
Moline |
Rock Island |
Illinois |
Adrian Landeros |
Emanuel Landeros |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Emanuel Landeros |
fland1983@gmail.com |
Brother |
Moline |
Rock Island |
Illinois |
Adrian Landeros |
Emanuel Landeros |
Signed |
260 |
2020-09-17 10:52 |
Anonymous (not verified) |
50.80.218.18 |
Decanus Property Management |
Proprietorship |
102 E 2nd St, Davenport IA 52801 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-17 |
Shonna Suzanne Dean |
decanus@yahoo.com |
Moline |
Rock Island |
Illinois |
Justin E Proctor |
Elizabeth A Oney |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shonna S Dean |
decanus@yahoo.com |
Self |
Moline |
Rock Island |
Illinois |
Justin E Proctor |
Elizabeth A Oney |
Signed |
320 |
2020-11-17 10:08 |
Anonymous (not verified) |
65.103.82.36 |
Brian Behnkendorf dba Dutchmen Services |
Proprietorship |
55 Rose Court West, Geneseo IL 61254 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-13 |
Brian Behnkendorf |
4gbbehnk@gmail.com |
Geneseo |
Henry |
Illinois |
Kayla Artioli |
Eric Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Behnkendorf |
4gbbehnk@gmail.com |
Self |
Geneseo |
Henry |
Illinois |
Kayla Artioli |
Eric Johnson |
Signed |
598 |
2021-08-06 19:04 |
Anonymous (not verified) |
107.77.208.84 |
Paul Adams |
Proprietorship |
914 Bayfield drive Denton TX 76209 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-06 |
Paul T Adams |
ptadams61@yahoo.com |
Denton |
Denton |
Tx |
Jeanie Moses |
Richard Moses |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paul T Adams |
ptadams61@yahoo.com |
Friends |
Milan |
Rock Island |
Illinois |
Jeanie Moses |
Richard Moses |
Signed |
647 |
2021-09-20 10:37 |
Anonymous (not verified) |
173.29.34.49 |
Brandon Jones |
Proprietorship |
2043 3x Avenue |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-20 |
Brandon Dederick Jones |
Kaleb0430jones@gmail.com |
East Moline |
United States |
Illinois |
Brandon Jones |
Brandon Jones |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brandon Dederick Jones |
Kaleb0430jones@gmail.com |
self |
East Moline |
United States |
Illinois |
Brandon Jones |
Brandon Jones |
Signed |
901 |
2022-02-06 16:48 |
Anonymous (not verified) |
50.83.154.236 |
Cole Jurgle |
Proprietorship |
409 West riverside drive prophetstown IL 61277 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-05 |
Cole Alexander Jurgle |
cole.jurgle@gmail.com |
Prophetstown |
Whiteside |
Illinois |
Nicholas Ray Jurgle |
Misty Ann Jurgle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cole Alexander Jurgle |
cole.jurgle@gmail.com |
self |
Prophetstown |
Whiteside |
Illinois |
Nicholas Ray Jurgle |
Misty Ann Jurgle |
Signed |
1008 |
2022-03-25 15:15 |
Anonymous (not verified) |
174.192.130.230 |
Hill's Rehab &Landscape L.L.C |
Limited Liability Company |
3717 15th ave Moline Illinois 61365 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-25 |
Joshua hill |
joshuajameshill79@gmail.com |
Moline |
Rock Island |
Illinois |
Lindsay erin Hill |
NICOLE ann lear |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua james hill |
joshuajameshill79@gmail.com |
President |
Moline |
Rock Island |
Illinois |
Lindsay Erin Hill |
NIcole ann lear |
Signed |
1090 |
2022-05-06 08:08 |
Anonymous (not verified) |
65.111.39.23 |
Farr TRucking Inc |
Proprietorship |
2206 E Locust Ln, Table Grove, IL 61482 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-06 |
Donald Paul Farr |
howthewestisdone@gmail.com |
Table Grove |
Fulton |
Illinois |
Tamra Stambaugh |
Keith Allard |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
DeYonne L Farr |
howthewestisdone@gmail.com |
Secretary |
Table Grove |
Fulton |
Illinois |
Tamra Stambaugh |
Keith Allard |
Signed |
1526 |
2023-03-21 12:24 |
Anonymous (not verified) |
94.188.207.223 |
Quad Cities Transport Inc |
Proprietorship |
1106 46th ave Rock Island IL 61201 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-21 |
Howard Davis |
qctranaportinc@gmail.com |
East Moline |
Rock Island |
Illinois |
Ricky Oconner |
Patrick Watkins |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Howard Davis |
hdenterprisesinc14@gmail.com |
Owner |
East Moline |
Rock Island |
Illinois |
Patrick Watkins |
Ricky Oconner |
Signed |
1527 |
2023-03-22 08:35 |
Anonymous (not verified) |
94.188.205.167 |
Quad Cities Transport Inc |
Proprietorship |
1106 46th ave Rock Island IL 61201 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-21 |
Howard Rick Clark Davis |
hdenterprisesinc14@gmail.com |
East Moline |
Rock Island |
IL |
Patrick Watkins |
Ricky Oconner |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Howard Davis |
qctransportinc@gmail.com |
Owner |
East Moline |
Rock Island |
Illinois |
Ricky Oconner |
Patrick Watkins |
Signed |
1754 |
2023-07-19 08:52 |
Anonymous (not verified) |
94.188.207.224 |
Dustin Scoggins |
Limited Liability Company |
1723 19th ave rock island Illinois |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-19 |
Dustin Shane Scoggins |
dscoggins625@gmail.com |
Rock island |
Rock island county |
Illinois |
Emily Smith-Scoggins |
Emily Smith-Scoggins |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Shane Scoggins |
dscoggins625@gmail.com |
Self |
Rock island |
Rock island county |
Illinois |
Emily Smith-Scoggins |
Emily Smith-Scoggins |
Signed |
1848 |
2023-09-19 10:20 |
Anonymous (not verified) |
94.188.207.226 |
Josh Woodworth |
Proprietorship |
16405 u.s. 67 milan il 61264 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-19 |
Josh woodworth |
joshwoodworth84@live.com |
milan |
Rock island |
Illinois |
Cody dunbar |
Jordan nisiewicz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cody dunbar |
cdunbar@leaffilter.com |
Install manager |
moline |
Rock island |
illinois |
Cody dunbar |
Jordan nisiewic |
Signed |
2040 |
2024-02-08 10:35 |
Anonymous (not verified) |
94.188.207.226 |
Storm Pro Solution |
Limited Liability Company |
1309 Coffeen Sheridan,wy 82801 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-08 |
Candis Henderson |
Cneal@stormprosolution.com |
Broadview |
Chicago |
Illinois |
Chester Neal |
Eric Henderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Candis Henderson |
Cneal@stormprosolution.com |
Self |
Broadview |
Chicago |
Illinois |
Chester neal |
Eric Henderson |
Signed |
2160 |
2024-04-17 18:21 |
Anonymous (not verified) |
94.188.207.226 |
QC Remodeling LLC |
Limited Liability Company |
421 West Broadway, Ste 302 Council Bluffs, IA 51503 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-17 |
Fernando Ibarra |
ibarra_fernando@hotmail.com |
Rock Island |
Rock Island |
Illinois |
Paula Barria |
Louis Valencia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Fernando Ibarra |
ibarra_fernando@hotmail.com |
Owner |
Rock Island |
Rock Island |
Illinois |
Paula Barria |
Louis Valencia |
Signed |
2168 |
2024-04-22 08:18 |
Anonymous (not verified) |
94.188.207.228 |
Mattson's Floor Covering |
Proprietorship |
2073 Sandy Lane |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-22 |
Blaine Linn Mattson |
tmatzan99@yahoo.com |
Oquawka |
Henderson |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Blaine Mattson |
tmatzan22@yahoo.com |
owner |
Oquawka |
Henderson |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
2174 |
2024-04-24 08:22 |
Anonymous (not verified) |
94.188.205.175 |
White's Floorcovering |
Proprietorship |
129 Hillcrest Dr. Biggsville, IL 61418 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-22 |
Ron White |
hntwhite@frontiernet.net |
Biggsville |
Henderson |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ron White |
hntwhite@frontiernet.net |
owner |
Biggsville |
Henderson |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
2176 |
2024-04-24 11:12 |
Anonymous (not verified) |
94.188.205.176 |
Schutters Pest Control Inc. |
Limited Liability Company |
109 2nd Ave, Suite #2, Carbon Cliff,IL 61239 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-04 |
Billy Y Schutters |
schutterspestcontrol@gmail.com |
Bettendorf |
Iowa |
United States |
Aidan Sammon |
Kalissa Malin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Billy Y Schutters |
schutterspestcontrol@gmail.com |
Same Person |
Carbon Cliff |
Rock Island |
Illinois |
Aidan Sammon |
Kalissa Malin |
Signed |
2191 |
2024-04-29 10:09 |
Anonymous (not verified) |
94.188.207.225 |
Anthony Rakestraw |
Proprietorship |
1262 S Kellogg St., Galesburg, IL 61401 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-29 |
Anthony Rakestraw |
gazzork2@yahoo.com |
Galesburg |
Know |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Anthony Rakestraw |
gazzork2@yahoo.com |
owner |
Galesburg |
Knox |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
256 |
2020-09-14 09:38 |
Anonymous (not verified) |
66.188.136.150 |
Steven Headlee |
Proprietorship |
671 Metaire Drive Apt. A, Greenwood, IN 46143 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-14 |
Steven Headlee |
kschumacher@tricorinsurance.com |
Greenwood |
Johnson |
IN |
Nancy Wortley |
Russell Masartis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steven Headlee |
kschumacher@tricorinsurance.com |
Same |
Greenwood |
Johnson |
IN |
Nancy Wortley |
Russell Masartis |
Signed |
428 |
2021-03-10 12:38 |
Anonymous (not verified) |
66.188.136.150 |
John Smith |
Proprietorship |
2490 E Main St. Lot 41, Plainfield, IN 46168 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-10 |
John Smith |
kschumacher@tricorinsurance.com |
Plainfield |
Hendricks |
IN |
Russell Masartis |
Amanda Seeberger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Smith |
kschumacher@tricorinsurance.com |
Same |
Plainfield |
Hendricks |
IN |
Russell Masartis |
Amanda Seeberger |
Signed |
450 |
2021-03-25 11:59 |
Anonymous (not verified) |
66.188.136.150 |
Mason Cook |
Proprietorship |
10604 Bradford Road, Indianapolis, IN 46231 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-23 |
Mason Cook |
kschumacher@tricorinsurance.com |
Indianapolis |
Marion |
IN |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mason Cook |
kschumacher@tricorinsurance.com |
Same |
Indianapolis |
Marion |
IN |
Russell Masartis |
Shuree Behr |
Signed |
515 |
2021-05-11 15:18 |
Anonymous (not verified) |
66.188.136.150 |
Odie Mitchell |
Proprietorship |
10441 Serenity Dr. DeMotte, IN 46310 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-05 |
Odie Mitchell |
kschumacher@tricorinsurance.com |
DeMotte |
Jasper |
IN |
Shuree Behr |
Jordan Bass |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Odie Mitchell |
kschumacher@tricorinsurance.com |
Same |
DeMotte |
Jasper |
IN |
Shuree Behr |
Jordan Bass |
Signed |
516 |
2021-05-12 12:41 |
Anonymous (not verified) |
66.188.136.150 |
Odie Mitchell |
Proprietorship |
10441 Serenity Dr. DeMotte, IN 46310 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-05 |
Odie Mitchell |
kschumacher@tricorinsurance.com |
DeMotte |
Jasper |
IN |
Shuree Behr |
Jordan Bass |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Odie Mitchell |
kschumacher@tricorinsurance.com |
Same |
DeMotte |
Jasper |
IN |
Shuree Behr |
Jordan Bass |
Signed |
553 |
2021-07-01 08:17 |
Anonymous (not verified) |
66.188.136.150 |
Cody Belleville |
Proprietorship |
57167 Copperdate Dr. Elkhart, IN 46516 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-30 |
Cody Belleville |
kschumacher@tricorinsurance.com |
Elkhart |
Elkhart |
IN |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cody Belleville |
kschumacher@tricorinsurance.com |
Same |
Elkhart |
Elkhart |
IN |
Mitch Kemp |
Shuree Behr |
Signed |
1431 |
2023-01-25 16:24 |
Anonymous (not verified) |
172.56.249.51 |
Warren transport |
Limited Liability Company |
3124 titan trail Waterloo,iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-25 |
Lamarcaus Lunford |
universalvoyager1@gmail.com |
Elkhart |
IN |
Indiana |
Quinetta shead |
Eric fikes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lamarcaus Lunford |
universalvoyager1@gmail.com |
Owner |
Elkhart |
IN |
Indiana |
Quinetta shead |
Eric fikes |
Signed |
1326 |
2022-10-04 10:27 |
Anonymous (not verified) |
70.96.153.153 |
Bright Fame Inc |
Limited Liability Company |
2185 NW 149th St, Clive, IA 50325 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-04 |
Robert Ferguson |
robert@optionsexteriors.com |
Clive |
Dallas |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert Ferguson |
robert@optionsexteriors.com |
Owner/Self |
Clive |
Dallas |
Iosa |
Charlotte Rasmussen |
Austin Miller |
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 |
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 |
7 |
2019-11-15 12:26 |
Anonymous (not verified) |
173.17.129.166 |
Thomas C. Davis |
Proprietorship |
3509 Franklin Ave, Des Moines, IA 50310 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-11-15 |
Thomas C. Davis III |
thomas.davis.iii@gmail.com |
Des Moines |
Polk |
Iowa |
Jared Vincent |
Kevin Corn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Thomas C. Davis III |
thomas.davis.iii@gmail.com |
Employer |
Des Moines |
Polk |
Iowa |
Jared Vincent |
Kevin Corn |
Signed |
8 |
2019-12-13 12:18 |
Anonymous (not verified) |
173.18.3.76 |
Knight Electric, LLC |
Limited Liability Company |
200 E Aurora 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. |
2019-12-13 |
Ryan Lewis |
ryan@knightelectric.biz |
Des Moines |
Polk |
Iowa |
Angie Kinsey |
Jon Stetzel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Lewis |
ryan@knightelectric.biz |
Member/Owner |
Des Moines |
Polk |
Iowa |
Angie Kinsey |
Jon Stetzel |
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 |
17 |
2019-12-31 09:24 |
Anonymous (not verified) |
72.35.186.80 |
Grgurich Dozing & Tiling, LLC |
Partnership |
PO Box 131, Williamson, IA 50272 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Seth Grgurich |
mcbroomt15@gmail.com |
Williamson |
Lucas |
Iowa |
Eric Curran |
Stacy Smyser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Seth Grgurich |
mcbroomt15@gmail.com |
Partner |
Williamson |
Lucas |
Iowa |
Eric Curran |
Stacy Smyser |
Signed |
18 |
2019-12-31 13:36 |
Anonymous (not verified) |
162.253.44.28 |
Wade Roth DBA Roth TV and Appliance |
Proprietorship |
1004 12th St, Belle Plaine, IA 52208 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2019-12-09 |
Wade Roth |
WADEROTH@NETINS.NET |
Belle PLaine |
Benton |
Iowa |
Robert Sydnes |
Robert Sydnes |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Wade Roth |
WADEROTH@NETINS.NET |
Self |
Belle Plaine |
Benton |
Iowa |
Robert Sydnes |
Kurt Feller |
Signed |
21 |
2020-01-01 18:16 |
Anonymous (not verified) |
72.35.186.80 |
Jerry Arnold |
Proprietorship |
1426 25th St, Humeston, IA 50123 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-01 |
Jerry Arnold |
LLArnold62@gmail.com |
Humeston |
Wayne |
Iowa |
Fred Throckmorton |
Joyce Throckmorton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jerry Arnold |
LLArnold62@gmail.com |
Self |
Humeston |
Wayne |
Iowa |
Fred Throckmorton |
Joyce Throckmorton |
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 |
24 |
2020-01-03 12:41 |
Anonymous (not verified) |
63.152.13.239 |
Eden Plumbing LLC TJ Eden |
Limited Liability Company |
502 Packwaukee Street New Hartford, IA 50660 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-03 |
TJ Eden |
edentj@aol.com |
New Hartford |
IA |
United States |
Ann Robinson |
Nate Schmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
PDCM Insurance- Nate Schmidt |
NSCHMIDT@PDCM.COM |
Member |
New Hartford |
Butler |
Iowa |
Ann Robinson |
Nate Schmidt |
Signed |
25 |
2020-01-03 13:09 |
Anonymous (not verified) |
74.84.121.206 |
Raymond Jones |
Proprietorship |
P O Box 682 Monona IA 52159 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-11-29 |
Raymond Jones |
darrele@ciains.biz |
Monona |
Clayton |
Iowa |
Darrel J Elsbernd |
Chris Fye |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Darrel J Elsbernd |
darrele@ciains.biz |
insurance agent |
Lime Springs |
Howard |
Iowa |
Darrel J Elsbernd |
Chris Fye |
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 |
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 |
31 |
2020-01-07 08:37 |
Anonymous (not verified) |
199.10.5.7 |
Data Information Management LLC |
Limited Liability Company |
703 Bluff St Dubuque IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-07 |
Christopher R Broessel |
chris@caricomm.com |
Dubuque |
Dubuque |
IA |
Janet L Schauff |
Morris P Schauff |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stephen M schauff |
steve@caricomm.com |
Partner |
Dubuque IA |
Dubuque |
Iowa |
Janet L schauff |
Morris P Schauff |
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 |
34 |
2020-01-10 15:56 |
Anonymous (not verified) |
74.84.121.206 |
Milferd Loewen |
Proprietorship |
6568 Hwy 63, Lime Springs, IA 52155 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-10 |
Milferd Loewen |
darrele@ciains.biz |
Lime Springs |
Howard |
Iowa |
Darrel J. Elsbernd |
Chris Fye |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Milferd Loewen |
darrele@ciains.biz |
self |
Lime Springs |
Howard |
Iowa |
Darrel J. Elsbernd |
Chris Fye |
Signed |
35 |
2020-01-13 13:23 |
Anonymous (not verified) |
173.28.28.57 |
Milkhouse Market, LLC |
Limited Liability Company |
911 Parriott Street, Aplington IA 50604 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-30 |
MARY MEYER |
cmins_re@mchsi.com |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MARY MEYER |
cmins_re@mchsi.com |
Self |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
36 |
2020-01-15 13:26 |
Anonymous (not verified) |
173.28.28.57 |
Shirley Pepples |
Proprietorship |
206 4th Street, Parkersburg, IA 50665 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-14 |
Shirley Pepples |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shirley Pepples |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
37 |
2020-01-16 15:26 |
Anonymous (not verified) |
173.24.236.134 |
Eric Krueger |
Proprietorship |
406 NE Oak Dr. Ankeny, IA 50021 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-16 |
Eric Lucas Krueger |
erickrugs@gmail.com |
Ankeny |
Polk |
Iowa |
Emily Marie Krueger |
Roberty William Krueger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Eric Krueger |
erickrugs@gmail.com |
self |
Ankeny |
Polk |
Iowa |
Emily Marie Krueger |
Robert William Krueger |
Signed |
38 |
2020-01-18 12:15 |
Anonymous (not verified) |
206.109.174.199 |
BJS Frenchies, LLC |
Limited Liability Company |
20081 Highway J 46 Centerville Iowa 52544 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-06 |
J. Jamie Tracy |
jamiespuppies@yahoo.com |
Centerville |
Appanoose |
Iowa |
Misty O'Hair |
Casey Leach |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bruce E Tracy |
jamiespuppies@yahoo.com |
Husband and Co Owner |
Centerville |
Appanoose |
Iowa |
Misty O'Hair |
Casey Leach |
Signed |
43 |
2020-01-27 09:23 |
Anonymous (not verified) |
71.199.85.251 |
ATW Training |
Limited Liability Company |
4414 114th Street, Urbandale Iowa 50322 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-25 |
Heather Hampton Cooper |
hcooper1@comcast.net |
Saint Augustine |
Saint Johns |
Florida |
Terry Lee Cooper |
Stacy Thatcher |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lynn Roberts |
Lynne@atwtraining.com |
HR |
Des Moines |
Polk |
Iowa |
Cathy Belmont |
Mark Purcell |
Signed |
45 |
2020-01-28 16:13 |
Anonymous (not verified) |
173.18.3.76 |
Delic Marble and Tile LLC |
Limited Liability Company |
24 Ellefson Dr PO Box 413 DeSoto, IA 50069 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-31 |
Adin Delic |
delicgraniteandtile@gmail.com |
Adel |
Dallas |
Iowa |
Angela Kinsey |
Taylor Benshoof |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lutfija Delic |
delicgraniteandtile@gmail.com |
LLC Member |
Adel |
Dallas |
Iowa |
Angela Kinsey |
Taylor Benshoof |
Signed |
46 |
2020-01-28 16:32 |
Anonymous (not verified) |
173.18.3.76 |
Delic Marble and Tile LLC |
Limited Liability Company |
24 Ellefson Dr PO Box 413 DeSoto, IA 50069 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2020-01-27 |
Lutfija Delic |
delicgraniteandtile@gmail.com |
Adel |
Dallas |
Iowa |
Angela Kinsey |
Taylor Benshoof |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adin Delic |
delicgraniteandtile@gmail.com |
LLC Member |
Adel |
Dallas |
Iowa |
Angela Kinsey |
Taylor Benshoof |
Signed |
47 |
2020-01-28 16:35 |
Anonymous (not verified) |
173.18.3.76 |
Delic Marble and Tile LLC |
Limited Liability Company |
24 Ellefson Dr PO Box 413 DeSoto, IA 50069 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Sabahudin Delic |
delicgraniteandtile@gmail.com |
Adel |
Dallas |
Iowa |
Angela Kinsey |
Taylor Benshoof |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adin Delic |
delicgraniteandtile@gmail.com |
LLC Member |
Adel |
Dallas |
Iowa |
Angela Kinsey |
Taylor Benshoof |
Signed |
48 |
2020-01-29 13:52 |
Anonymous (not verified) |
97.64.170.98 |
DARIN J. KESSLER |
Proprietorship |
1236 25TH ST AMES, IA 50010 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-29 |
DARIN J. KESSLER |
darinjkessler@gmail.com |
AMES |
STORY |
IOWA |
HEATHER DIANNE LANNING |
JENNY ANN ARENDS |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
DARIN J. KESSLER |
darinjkessler@gmail.com |
SELF |
AMES |
STORY |
IOWA |
HEATHER DIANNE LANNING |
JENNY ANN ARENDS |
Signed |
49 |
2020-01-31 12:53 |
Anonymous (not verified) |
74.84.121.206 |
Cody Kleppe |
Proprietorship |
1891 337th St 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. |
2020-01-31 |
Cody Kleppe |
darrele@ciains.biz |
Decorah |
Winneshiek |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Darrel Elsbernd |
darrele@ciains.biz |
agent |
Decorah |
Winneshiek |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
50 |
2020-02-03 14:55 |
Anonymous (not verified) |
173.28.28.57 |
Silverleaf Capital, LLC |
Limited Liability Company |
1606 Palmer Court, Parkersburg IA 50665 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Silverleaf Capital, LLC |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Silverleaf Capital, LLC |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
51 |
2020-02-04 10:31 |
Anonymous (not verified) |
173.28.28.57 |
Sister Style, LLC |
Limited Liability Company |
211 3rd Street, Parkersburg IA 50665 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Lisa Ellis |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lisa Ellis |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
52 |
2020-02-04 10:35 |
Anonymous (not verified) |
173.28.28.57 |
Sister Style, LLC |
Limited Liability Company |
211 3rd Street, Parkersburg IA 50665 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Amanda Jorgenson |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Amanda Jorgenson |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
54 |
2020-02-06 14:18 |
Anonymous (not verified) |
173.28.28.57 |
Dale Hansman dba Klinkenborg Hansmann Law Office |
Proprietorship |
1201 Hwy 57, Parkersburg, IA 50665 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-14 |
Dale Hansmann |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dale Hansmann |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
57 |
2020-02-10 15:33 |
Anonymous (not verified) |
198.167.182.164 |
AllEnhancements LLC |
Limited Liability Company |
1122 Woodland Ln, LeClaire, IA 52753 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-31 |
Brett Allen |
allenhancementsllc@outlook.com |
LeClaire |
Scott |
Iowa |
Steven J Fishman |
E Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brett Allen |
allenhancementsllc@outlook.com |
Managing Member |
LeClaire |
Scott |
Iowa |
Steven J Fishman |
E Dyan Kriener |
Signed |
58 |
2020-02-10 21:18 |
Anonymous (not verified) |
75.162.11.63 |
Moni tile Services llc |
Limited Liability Company |
2207 E Walnut St des Moines iowa 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-01 |
Monica M Sandoval |
Mjsandoval20@yahoo.com |
Des Moines |
Polk |
United States |
Cassie Ann bentz |
James wesley harkert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Moni tile services llc |
Mjsandoval20@yahoo.com |
Self |
Des Moines |
Polk |
Iowa |
Cassie Ann bentz |
James wesley harkert |
Signed |
59 |
2020-02-11 11:34 |
Anonymous (not verified) |
198.167.182.164 |
Besch Electric LLC |
Limited Liability Company |
317 Sycamore St, Riverside, IA 52327 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-03 |
Daniel Besch |
beschd@hotmail.com |
Riverside |
Washington |
Iowa |
Steven J Fishman |
E Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Besch |
beschd@hotmail.com |
Managing Member |
Riverside |
Washington |
Iowa |
Steven J Fishman |
E Dyan Kriener |
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 |
64 |
2020-02-18 10:02 |
Anonymous (not verified) |
198.167.182.164 |
Elite Electrical Service LLC |
Limited Liability Company |
2035 Lynncrest Dr, Coralville, IA 52241 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-18 |
Sean Brogan |
brogan_sean@hotmail.com |
Coralville |
Johnson |
Iowa |
Kyle Stahle |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sean Brogan |
brogan_sean@hotmail.com |
Managing Member |
Coralville |
Johnson |
Iowa |
Kyle Stahle |
Dyan Kriener |
Signed |
66 |
2020-02-19 08:48 |
Anonymous (not verified) |
170.232.227.246 |
CRS Inc |
Proprietorship |
1442 3rd Ave SW 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. |
2020-02-19 |
Rebecca Gardner |
beckygard1018@gmail.com |
Waverly |
Bremer |
Iowa |
Sarah Lowe |
Kelsey Poe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rebecca Gardner |
beckygard1018@gmail.com |
Consultant |
Waverly |
Bremer |
Iowa |
Sarah Lowe |
Kelsey Poe |
Signed |
67 |
2020-02-19 10:16 |
Anonymous (not verified) |
198.167.182.164 |
AWF579 LLC |
Limited Liability Company |
13 Lynden Dr NE, 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. |
2020-02-18 |
Jeffrey Schiltz |
jeffschiltz2@yahoo.com |
Iowa City |
Johnson |
Iowa |
Kyle Stahle |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeffrey Schiltz |
jeffschiltz2@yahoo.com |
Managing Member |
Iowa City |
Johnson |
Iowa |
Kyle Stahle |
Dyan Kriener |
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 |
72 |
2020-02-21 09:43 |
Anonymous (not verified) |
98.18.174.183 |
Forrest E. Whitford DVM LLC |
Limited Liability Company |
P.O. Box 120 - 507 Washington Street, Volga, IA 52077 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-21 |
Forrest E. Whitford, DVM LLC |
gfw54@hotmail.com |
Volga, IA |
Clayton |
Iowa |
Glenna Whitford |
Pam Vaske |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Forrest E. Whitford, DVM LLC |
gfw54@hotmail.com |
self |
Volga |
Clayton |
Iowa |
Glenna Whitford |
Pam Vaske |
Signed |
73 |
2020-02-21 13:44 |
Anonymous (not verified) |
192.30.185.233 |
Viejos Masnry construction LLC |
Limited Liability Company |
1708 Villa Ave. Sioux City IA 51103 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-13 |
Oscar Castro Ramirez |
veijosconstruction@gmail.com |
Sioux City |
Woodbury |
Iowa |
JEFFREY H MCCLINTOCK |
Nancy Fleming |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Viejos Masonry Construction LLC |
veijosconstruction@gmail.com |
Owner/President |
SIOUX CITY |
Woodbury |
Iowa |
Nancy Fleming |
Jeffrey Hugh McClintock |
Signed |
74 |
2020-02-24 15:00 |
Anonymous (not verified) |
97.64.133.18 |
Sky Roofing LLC |
Partnership |
1332 Idaho St., Des Moines, IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-01 |
Ramiro Jurado Gomez |
Liberty21424@gmail.com |
Des Moines |
Polk |
IA |
Valerie Cramer |
David Murray |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Valerie Cramer |
cramerlaw@halousa.com |
Attorney |
Des Moines |
Polk |
Iowa |
David Murray |
Sara McGinnis |
Signed |
75 |
2020-02-24 15:03 |
Anonymous (not verified) |
97.64.133.18 |
Sky Roofing LLC |
Partnership |
1332 Idaho St., Des Moines, IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-01 |
Ramiro Jurado Bucio |
Liberty21424@gmail.com |
des moines |
Polk |
Iowa |
Valerie Cramer |
David Murray |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Valerie Cramer |
cramerlaw@halousa.com |
Attorney |
Des Moines |
Polk |
Iowa |
David Murray |
Sara McGinnis |
Signed |
76 |
2020-02-24 15:05 |
Anonymous (not verified) |
97.64.133.18 |
Sky Roofing |
Partnership |
1332 Idaho St., Des Moines, IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-01 |
Angel Jurado |
Liberty21424@gmail.com |
des moines |
Polk |
Iowa |
Valerie Cramer |
David Murray |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cramer Law PLC |
cramerlaw@halousa.com |
Attorney |
Polk |
Polk |
Iowa |
Sara Mc Ginnis |
David Murray |
Signed |
77 |
2020-02-24 15:07 |
Anonymous (not verified) |
97.64.133.18 |
Sky Roofing LLC |
Partnership |
1332 Idaho St., Des Moines, IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-01 |
Victor Jurado |
Liberty21424@gmail.com |
des moines |
Polk |
Iowa |
David Murray |
Valerie Cramer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cramer Law PLC |
Liberty21424@gmail.com |
Attorney |
DES MOINES |
POlk |
Iowa |
David Murray |
Sara McGinnis |
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 |
84 |
2020-02-28 15:30 |
Anonymous (not verified) |
198.167.182.164 |
Rid-A-Bird Inc. |
Limited Liability Company |
3116 Friendship St. Iowa City IA 52245 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Keith Wilson |
kwilson@windowgenie.com |
Iowa City |
Johnson |
Iowa |
Dyan Kriener |
Marcia A Colvin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Keith Wilson |
kwilson@windowgenie.com |
Managing member |
Iowa City |
Johnson |
Iowa |
Dyan Kriener |
Marcia A Colvin |
Signed |
85 |
2020-03-09 08:17 |
Anonymous (not verified) |
198.167.182.164 |
Simply Anchored LLC dba Simply Mae's |
Limited Liability Company |
601 Broad St, Story City, IA 50248 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Jessi Kettenacker |
jessi@simplymaes.com |
Story City |
Story |
Iowa |
Lynn McKinney |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jessi Kettenacker |
jessi@simplymaes.com |
Managing Member |
Story City |
Story |
Iowa |
Lynn McKinney |
Dyan Kriener |
Signed |
86 |
2020-03-09 08:19 |
Anonymous (not verified) |
198.167.182.164 |
Simply Anchored LLC dba Simply Mae's |
Limited Liability Company |
601 Broad St, Story City, IA 50248 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Cande Coulter |
cande@simplymaes.com |
Story City |
Story |
Iowa |
Lynn McKinney |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Candy Coulter |
cande@simplymaes.com |
Managing Member |
Story City |
Story |
Iowa |
Lynn McKinney |
Dyan Kriener |
Signed |
90 |
2020-03-13 15:44 |
Anonymous (not verified) |
173.24.190.134 |
Heath Householder |
Limited Liability Company |
2 N Huron Street, Emmetsburg IA 50536 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-07 |
Heath Householder |
heath679@live.com |
Emmetsburg |
Palo Alto |
Iowa |
Scott Wirtz |
Candie Clark |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Heath Householder |
heath679@live.com |
Member of LLC |
Emmetsburg |
Palo Alto |
Iowa |
Scott Wirtz |
Candie Clark |
Signed |
91 |
2020-03-13 15:51 |
Anonymous (not verified) |
173.24.190.134 |
Small Town RV, LLC |
Limited Liability Company |
112 Miller 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. |
2020-03-09 |
Heath Sabin |
sales@smalltownrv.com |
Mallard |
Palo Alto |
Iowa |
Dave Walters |
Candie Clark |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Heath Sabin |
sales@smalltownrv.com |
Member of LLC |
Mallard |
Palo Alto |
Iowa |
Dave Walters |
Candie Clark |
Signed |
92 |
2020-03-13 15:53 |
Anonymous (not verified) |
173.24.190.134 |
Tammy Sabin |
Limited Liability Company |
112 Miller 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. |
2020-03-09 |
Tammy Sabin |
sales@smalltownrv.com |
Mallard |
Palo Alto |
Iowa |
Dave Walters |
Candie Clark |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tammy Sabin |
sales@smalltownrv.com |
Member of LLC |
Mallard |
Palo Alto |
Iowa |
Dave Walters |
Candie Clark |
Signed |
93 |
2020-03-16 08:01 |
Anonymous (not verified) |
174.217.14.119 |
DOUBLE J CONTRACTING LLC |
Limited Liability Company |
18693 335TH LN, EARLHAM, IA 50072 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-16 |
JOSHUA D OSCARSON |
double-j-llc@outlook.com |
EARLHAM |
DALLAS |
IOWA |
Tim Hudson |
Kevin Gomez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Douglas Oscarson |
double-j-llc@outlook.com |
Business Manager |
Earlham |
Dallas |
Iowa |
Tim Hudson |
Kevin Gomez |
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 |
100 |
2020-03-24 15:46 |
Anonymous (not verified) |
216.51.130.87 |
Lake City Electric, LLC |
Limited Liability Company |
113 E Main Street, Lake City, IA 51449 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Lonnie R. Daisy |
lcelectric@iowatelecom.net |
Lake City |
Calhoun |
IOWA |
Sheryl Lynch |
Karen Prebeck |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lonnie R. Daisy |
lcelectric@iowatelecom.net |
self |
Lake City |
Calhoun |
IOWA |
Sheryl Lynch |
Karen Prebeck |
Signed |