881 |
2022-02-02 09:39 |
Anonymous (not verified) |
173.215.80.185 |
Tree & Forestry Equipment Inc |
Partnership |
201 Deer Haven St., Polk City, IA 50226 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-02 |
Deborah Frye |
deb@treeandforestry.com |
Polk City |
Polk |
IA |
Joshua Frye |
Phoebe Trent |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Deborah Frye |
deb@treeandforestry.com |
Self |
Polk City |
Polk |
IA |
Joshua Frye |
Phoebe Trent |
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 |
1534 |
2023-03-27 08:16 |
Anonymous (not verified) |
94.188.205.167 |
Richatd Deist |
Proprietorship |
1445 Hwy 71 Audubon IA 50025 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-26 |
Richard Deist |
deistfarms@hotmail.com |
Audubon |
IA |
United States |
Tara Deist |
Pat Groth |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bob Miller |
bob.miller@millerhybrids.com |
seed dealer |
Kalona ,Ia |
Washington |
IA |
Tara Deist |
Pat Groth |
Signed |
1535 |
2023-03-27 09:40 |
Anonymous (not verified) |
94.188.205.167 |
Richard Deist |
Proprietorship |
1445 hwy 71 Audubon Ia 50025 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-26 |
Richard Deist |
deistfarms@hotmail.com |
Audubon |
Audubon |
IA |
Tara Deist |
Pat Groth |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bob Miller |
bob.miller@millerhybrids.com |
Seed dealer |
Kalona |
Washington |
IA |
Tara Deist |
Pat Groth |
Signed |
1115 |
2022-05-17 19:36 |
Anonymous (not verified) |
173.23.50.204 |
Delgado Electrical Services |
Limited Liability Company |
1210 Creston Ave Des Moines, Iowa 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-17 |
Cesar Delgado |
delgado.electrical@gmail.com |
Des Moines |
Polk |
Iowa |
Mike Willet |
Alex Segovia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cesar Delgado |
cesar.delgado31@yahoo.com |
Owner |
Des Moines |
Polk |
Iowa |
Mike Willet |
Alex Segovia |
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 |
115 |
2020-04-09 11:42 |
Anonymous (not verified) |
67.60.46.104 |
D&H Plumbing, L.L.C |
Limited Liability Company |
44214 260th St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-05 |
Delwayne Merrill Abbott |
del_abbott@yahoo.com |
Kingsley |
Plymouth |
Iowa |
Doug Alan Gerdes |
Nick William Lahrs |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Delwayne Merrill Abbott |
brettherbold@gmail.com |
Owner |
Kingsley |
Plymouth |
Iowa |
Doug Alan Gerdes |
Nick William Lahrs |
Signed |
2053 |
2024-02-22 11:29 |
Anonymous (not verified) |
94.188.205.166 |
Demir sehic |
Proprietorship |
4052 Lafayette road |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-22 |
Demir Sehic |
Demirsehic123@gamil.com |
Waterloo |
IA |
United States |
Jordan nisiewicz |
Jordan Loyd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan nisiewicz |
jnisiewicz@leafhome.com |
Recurring |
Kansas city |
Jackson |
Mo |
Demir sehic |
Jordan Loyd |
Signed |
1920 |
2023-11-22 08:40 |
Anonymous (not verified) |
94.188.205.166 |
Demolition Services of Iowa, llc |
Limited Liability Company |
221 North Grant Ave., Elkhart, IA 50073 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-22 |
William Albert Halterman |
DemolitionServicesIA@gmail.com |
ELKHART |
IA |
United States |
Ashley Whitehill |
Zach Whitehill |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Albert Halterman |
DemolitionServicesIA@gmail.com |
self |
Elkhart |
Polk |
IA |
Ashley Nicole Lee Whitehill |
Zachery Allen Whitehill |
Signed |
819 |
2022-01-02 11:39 |
Anonymous (not verified) |
184.94.130.66 |
derek verhelst trucking inc |
Proprietorship |
1579 270th avenue canby mn 56220 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-02 |
derek verhelst |
derekvtinc@gmail.com |
canby |
yellow medicine |
mn |
lois verhelst |
dylan nelson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
derek verhelst |
derekvtinc@gmail.com |
owner |
canby |
yellow medicine |
mn |
lois verhelst |
dylan nelson |
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 |
1402 |
2022-12-28 16:35 |
Anonymous (not verified) |
208.69.145.91 |
DeRonde Flooring Inc. |
Proprietorship |
3612 NW 178th Ct, 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. |
2022-12-28 |
Brian DeRonde |
derondeflooring@gmail.com |
Clive |
Dallas |
IA |
Brian DeRonde |
Courtney DeRonde |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian DeRonde |
derondeflooring@gmail.com |
Self |
Clive |
Dallas |
IA |
Brian DeRonde |
Courtney DeRonde |
Signed |
2185 |
2024-04-26 16:46 |
Anonymous (not verified) |
94.188.205.166 |
Jerilyn Horn Kitchen and Bath Design Co. |
Proprietorship |
413 Jefferson St., Burlington, IA 52601 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-26 |
Jerilyn Michelle Horn |
designsbyjerilyn@gmail.com |
Mt. Pleasant |
Henry |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jerilyn Michelle Horn |
designsbyjerilyn@gmail.com |
owner |
Mt. Pleasant |
Henry |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
2129 |
2024-04-01 14:16 |
Anonymous (not verified) |
94.188.207.227 |
Des Moines Construction LLC |
Limited Liability Company |
6615 SE 3rd St Des Moines IA 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-01 |
Rodrigo Valdes |
desmoinesconstructionllc@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rodrigo Valdes |
desmoinesconstructionllc@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
1221 |
2022-07-21 13:40 |
Anonymous (not verified) |
129.222.3.107 |
Barkers Handyman Express |
Proprietorship |
120 S Mill St Gilman, IA 50106 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-22 |
Devin Levi Barker |
devinbarker91@gmail.com |
Gilman |
Marshall |
Iowa |
Emily Anne Barker |
Lloyd Owen Barker Jr. |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Devin Levi Barker |
devinbarker91@gmail.com |
Owner |
Gilman |
Marshall |
IA |
Emily Anne Barker |
Lloyd Owen Barker Jr. |
Signed |
1783 |
2023-08-04 10:17 |
Anonymous (not verified) |
94.188.207.229 |
Lundin trucking llc |
Limited Liability Company |
322 w wilson street preston iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-04 |
Devin dallas lundin |
devinlundin@hotmail.com |
Preston |
Jackson |
Iowa |
Kathy kilburg |
Greg kilburg |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Devin lundin |
devinlundin@hotmail.com |
Owner |
Preston |
Jackson |
Iowa |
Kathy kilburg |
Greg kilburg |
Signed |
790 |
2021-12-14 10:59 |
Anonymous (not verified) |
173.31.148.43 |
SILVER LAKE ACCOUNTING LLC |
Limited Liability Company |
178 W BAY RD |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-13 |
DARYA GAY |
DGAY@SILVERLAKEACCOUNTING.CPA |
LAKE PARK |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
DARYA GAY |
DGAY@SILVERLAKEACCOUNTING.CPA |
SELF |
LAKE PARK |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
1193 |
2022-07-08 10:18 |
Anonymous (not verified) |
173.18.22.217 |
OWWT |
Limited Liability Company |
1915 SE Clovere Ridge 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. |
2022-07-08 |
Robert M Jackson |
dgfl08051982@gmail.com |
Ankeny |
Polk |
IA |
Lesa Reeves |
Erick Schuldt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert M Jackson |
dgfl08051982@gmail.com |
Owner |
Ankeny |
Polk |
Iowa |
Lesa Reeves |
Erick Sculdt |
Signed |
1057 |
2022-04-18 12:53 |
Anonymous (not verified) |
204.16.59.10 |
Iowa’s Gutter Specialist LLC |
Limited Liability Company |
1390 Lark Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-18 |
Dustin Halverson |
dh42312695@gmail.com |
Hampton |
IA |
United States |
Heather Halverson |
Michael Halverson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Halverson |
dh42312695@gmail.com |
Owner |
Hampton |
IA |
United States |
Heather Marie Halverson |
Michael Alexander Halverson |
Signed |
1370 |
2022-11-13 19:49 |
Anonymous (not verified) |
174.213.144.30 |
Iowa’s Gutter Specialist |
Limited Liability Company |
1390 Lark Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-21 |
Dustin Halverson |
dh42312695@gmail.com |
Hampton |
IA |
United States |
Patricia Reynolds |
Heather Halverson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Halverson |
dh42312695@gmail.com |
Owner |
Hampton |
IA |
United States |
Patricia Marie Reynolds |
Heather Marie Halverson |
Signed |
2078 |
2024-03-06 16:19 |
Anonymous (not verified) |
94.188.207.228 |
Iowa's Gutter Specialist LLC |
Limited Liability Company |
221 4th St SE Hampton Iowa 50441 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-06 |
Dustin Halverson |
dh42312695@gmail.com |
Hampton |
Iowa |
United States |
Levi Paine |
Amy Hayes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Halverson |
dh42312695@gmail.com |
Owner |
Hampton |
Iowa |
United States |
Levi Paine |
Amy Hayes |
Signed |
1321 |
2022-09-26 08:16 |
Anonymous (not verified) |
204.141.215.159 |
Leaf filter |
Limited Liability Company |
615 J Ave NE Cedar Rapids, Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-26 |
Dustin Hansen |
dhansen0925@gmail.com |
Marion |
Linn |
Iowa |
Audrianna Cleveland |
Trevor Frondle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Leaf filter |
sewell@leafhome.com |
N/a |
Cedar rapids |
Linn |
Iowa |
N/a |
N/a |
Signed |
919 |
2022-02-16 21:13 |
Anonymous (not verified) |
208.126.203.31 |
K & D Land Improvement, LLC |
Limited Liability Company |
2719 270th Street, Lehigh, Iowa 50557 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-16 |
Daniel Hansen |
dhansen@lvcta.com |
Lehigh |
Webster |
Iowa |
Karen Hansen |
Cathy Mickelson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Hansen |
dhansen@lvcta.com |
Member |
Lehigh |
Webster |
Iowa |
Karen Hansen |
Cathy Mickelson |
Signed |
1973 |
2024-01-02 17:05 |
Anonymous (not verified) |
94.188.207.227 |
Diego Puente |
Proprietorship |
1420 north st, apt#3 Perry Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-02 |
Diego Puente Martinez |
diegopuente0655@gmail.com |
Perry |
Dallas |
Iowa |
Jason Van Dyke |
Ashley Heffernen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jason Van Dyke |
jvandyke@thermalshop.com |
worker |
Cedar Rapids |
Iowa |
United States |
Jason Van Dyke |
Ashley Heffernen |
Signed |
490 |
2021-04-20 14:06 |
Anonymous (not verified) |
173.18.16.129 |
frey construction |
Limited Liability Company |
1388 205th st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-20 |
Dana Frey |
dingaf37@yahoo.com |
Creston |
Union |
Iowa |
Lesa Reeves |
Kelly Coluzzi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dana Frey |
dingaf37@yahoo.com |
owner |
Creston |
Union |
Iowa |
Lesa Reeves |
Kelly Coluzzi |
Signed |
699 |
2021-10-28 21:28 |
Anonymous (not verified) |
75.162.104.116 |
Hild Construction, LLC |
Limited Liability Company |
6439 NE 5th Ave, Pleasant Hill, IA 50327 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-28 |
Jason Hild |
dirtsailor133@gmail.com |
Pleasant Hill |
Iowa |
United States |
Scott Dart |
Michael Kramer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jason Hild |
dirtsailor133@gmail.com |
Self |
Pleasant Hill |
Polk |
United States |
Scott Dart |
Michael Kramer |
Signed |
982 |
2022-03-17 09:22 |
Anonymous (not verified) |
65.132.173.234 |
DAVE GARDNER CONSTRUCTION |
Proprietorship |
11936 KIMBALL AVE WATERLOO 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. |
2022-03-17 |
DAVE GARDNER |
djg201312@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Amy Picha |
Gary Rankin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dave Gardner |
djg201312@gmail.com |
self |
Waterloo |
Black Hawk |
IA |
Amy Picha |
Gary Rankin |
Signed |
1791 |
2023-08-08 15:22 |
Anonymous (not verified) |
94.188.207.227 |
dutch meadows lawn care |
Limited Liability Company |
304 W 9TH ST. S. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-08 |
david nunnikhoven |
djnunnik@iowatelecom.net |
newton |
Iowa |
United States |
david nunnikhoven |
david nunnikhoven |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
david nunnikhoven |
djnunnik@iowatelecom.net |
owner |
newton |
Iowa |
United States |
david nunnikhoven |
david nunnikhoven |
Signed |
1867 |
2023-10-16 12:34 |
Anonymous (not verified) |
94.188.205.176 |
North Bay Dock Service |
Proprietorship |
PO Box 374, Spirit Lake, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-16 |
Donald L. Johnson, Jr. |
djtjaj@outlook.com |
Spirit Lake |
Dickinson |
Iowa |
Michael Chozen |
April Bosma |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Teresa Johnson |
djtjaj@outlook.com |
bookkeeper |
Spirit Lake |
Dickinson |
Iowa |
Michael Chozen |
April Bosma |
Signed |
1555 |
2023-04-05 08:03 |
Anonymous (not verified) |
94.188.207.227 |
DK Motor Freight |
Proprietorship |
3621 Tyler Avenue |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-05 |
David Kirchner |
dkirchner89@gmail.com |
Hartley |
Obrien |
Iowa |
Janna VanDonge |
Chad Driesen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Kirchner |
dkirchner89@gmail.com |
Self |
Hartley |
Iowa |
United States |
Janna VanDonge |
Chad Driesen |
Signed |
963 |
2022-03-10 10:51 |
Anonymous (not verified) |
173.29.157.192 |
Thompson Servcies LLC |
Limited Liability Company |
21105 N Brady St., Davenport, IA 52806 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-10 |
Daniel M Konrardy |
dkonrardy64@yahoo.com |
Davenport |
Scott |
Iowa |
David Konrardy |
Cheryl Thompson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel M Konrardy |
dkonrardy64@yahoo.com |
LLC member/partner |
Davenport |
Scott |
Iowa |
David Konrardy |
Cheryl Thompson |
Signed |
1025 |
2022-04-01 09:32 |
Anonymous (not verified) |
173.23.251.188 |
Dakota Lester |
Proprietorship |
2711 Cedar St 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. |
2022-04-01 |
Dakota Lester |
dlester18@icloud.com |
Norwalk |
Warren |
Iowa |
Tara Murphy |
Mike Ryerson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dakota Lester |
dlester18@icloud.com |
owner |
Norwalk |
Warren |
Iowa |
Tara Murphy |
Mike Ryerson |
Signed |
1246 |
2022-08-08 12:33 |
Anonymous (not verified) |
174.215.249.59 |
Dustin Rambo |
Proprietorship |
4570, Hunter St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-07 |
Dustin Lee Rambo |
dlrambo80@gmail.com |
Palo |
USA |
IA |
Matt Lytle |
Jason Achenbach |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Rambo |
dlrambo80@gmail.com |
Self |
Palo |
USA |
IA |
Matt Lytle |
Jason Achenbach |
Signed |
438 |
2021-03-17 06:52 |
Anonymous (not verified) |
198.167.182.164 |
David L Ridnour |
Proprietorship |
1415 4th St, Perry, IA 50220 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-16 |
David L Ridnour |
dlridnour@gmail.com |
Perry |
Dallas |
Iowa |
Steve Fishman |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David L Ridnour |
dlridnour@gmail.com |
Owner |
Perry |
Dallas |
Iowa |
Steve Fishman |
Dyan Kriener |
Signed |
1887 |
2023-10-31 15:57 |
Anonymous (not verified) |
94.188.207.227 |
CEM BUSINESSES LLC |
Limited Liability Company |
608 evergreen cir nw Bondurant, IA 50035 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-31 |
Dustin Rudolph |
dmrudo@gmail.com |
Des Moines |
Polk |
Iowa |
Raelynn Aicher |
Cameron VanBuren |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dane McDonald |
dane.mcdonald@stellar-solar.net |
Self |
Bondurant |
Polk |
Iowa |
Raelynn Aicher |
Cameron VanBuren |
Signed |
1572 |
2023-04-13 11:12 |
Anonymous (not verified) |
94.188.205.167 |
CK Trucking |
Proprietorship |
24497 Hayes Street, Pleasantville, Iowa 50225 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-13 |
Craig Kooyman |
dmsstumpguy@yahoo.com |
Pleasantville |
IA |
IA |
Chad Randleman |
James Jordan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Craig Kooyman |
dmsstumpguy@yahoo.com |
Owner |
Pleasantville |
Warren |
IA |
Chad Randleman |
James Jordan |
Signed |
1145 |
2022-06-07 11:14 |
Anonymous (not verified) |
173.30.72.62 |
Swifty Enterprises |
Limited Liability Company |
1134 Capri Drive NE, Cedar Rapids, IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-07 |
Daniel Tabaka |
dmtabaka1@gmail.com |
Cedar Rapids |
Linn |
IA |
Wilma Janacek |
Fredrick Janacek |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Tabaka |
dmtabaka1@gmail.copm |
Self |
Cedar Rapids |
Linn |
IA |
Wilma Janacek |
Fredrick Janacek |
Signed |
1443 |
2023-02-07 10:05 |
Anonymous (not verified) |
166.181.84.211 |
Leaf home solutions |
Limited Liability Company |
1595 Georgetown rd Hudson Ohio 44236 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-07 |
Dean Martells |
dn.mardesconstruction@gmail.com |
Laporte city |
Benton |
Ia |
Jeromia wilson |
Todd mcknees |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Yurko |
byurko@leacome.com |
Recruiter |
Hudson |
Summit |
Ohio |
Brian mako |
Mat kaulig |
Signed |
902 |
2022-02-07 11:53 |
Anonymous (not verified) |
65.144.174.26 |
Donald Gardner Jr. |
Proprietorship |
625 NE 72nd Street, Pleasant Hill, Iowa 50327 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-07 |
Donald Gardner, Jr. |
dnagardner95@yahoo.com |
Pleasant Hill |
Polk |
Iowa |
Andrew West |
Braden Collins |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Donald Gardner, Jr. |
dnagardner95@yahoo.com |
Owner |
Pleasant Hill |
Polk |
Iowa |
Andrew West |
Braden Collins |
Signed |
1770 |
2023-07-31 14:21 |
Anonymous (not verified) |
94.188.205.168 |
D & G Communications |
Proprietorship |
405 1st St N., PO Box 11 Farley, Iowa 52046 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-31 |
Dave Hirsch |
dngcomm@hotmail.com |
Farley |
Dubuque |
Iowa |
Zack Hirsch |
Nick Hirsch |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dave Hirsch |
dngcomm@hotmail.com |
self |
Farley |
Dubuque |
Iowa |
Zach Hirsch |
Nick Hirsch |
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 |
1059 |
2022-04-19 15:06 |
Anonymous (not verified) |
64.186.23.83 |
CORRECTIONVILL GOLF CLUB, INC |
Limited Liability Company |
1300 HACKBERRY STREET, CORRECTIONVILLE IOWA 51016 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-19 |
NICK HEATH |
dogboy3485@yahoo.com |
CORRECTIONVILLE |
WOODBURY |
IOWA |
CANDACE JACOBSON |
AMBER HANSEN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KATIE EDWARDS |
kedwards@fnbcorrectionville.com |
SEC/TREASURER |
CORRECTIONVILLE |
WOODBURY |
IOWA |
CANDACE JACOBSON |
AMBER HANSEN |
Signed |
1968 |
2023-12-28 14:57 |
Anonymous (not verified) |
94.188.205.175 |
Rose Frimpong |
Proprietorship |
2110 NW 31st St. Ankeny, IA 50023 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-28 |
Rose Frimprong |
domena69@hotmail.com |
Ankeny |
Polk |
Iowa |
Amabilis Ngwa |
Chris Abonge |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rose Frimpong |
domena69@hotmail.com |
Self-employed |
Ankeny |
Polk |
Iowa |
Chris Abonge |
Amabilis Ngwa |
Signed |
1570 |
2023-04-12 18:09 |
Anonymous (not verified) |
94.188.205.166 |
Staley Engineering Consultants, LLC |
Limited Liability Company |
4212 Holland Drive, Des Moines, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-12 |
Donald K Staley |
Don.Staley@q.com |
Des Moines |
Iowa |
United States |
Kendall S. Staley |
Gary D. Hlavka |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Donald K Staley |
Don.Staley@q.com |
Owner |
Des Moines |
Iowa |
United States |
Kendall S. Staley |
Gary D. Hlavka |
Signed |
120 |
2020-04-14 14:58 |
Anonymous (not verified) |
66.188.136.150 |
Donald Hesseling |
Proprietorship |
3200 East Shaulis Rd., Waterloo, IA 50702 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-14 |
Donald Hesseling |
donkd0wgb@outlook.com |
Waterloo |
Blackhawk County |
IA |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dan Oberfoell |
doberfoell@tricorinsurance.com |
Agent |
Waterloo |
Blackhawk County |
IA |
Russell Masartis |
Nancy Wortley |
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 |
1142 |
2022-06-03 21:35 |
Anonymous (not verified) |
66.43.196.246 |
Doug ayers |
Proprietorship |
808 Willow st Dumont Iowa 50625 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-03 |
Doug dale ayers |
dougayers2612@gmail.com |
Dumont |
Butler |
Iowa |
Amy Pcha |
David Shear |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Doug ayers |
dougayers2612@gmail.com |
Owner operator |
Dumont |
Butler |
Iowa |
Amy Picha |
David Shear |
Signed |
1720 |
2023-07-05 07:19 |
Anonymous (not verified) |
94.188.207.224 |
Doug FGerneding |
Proprietorship |
21618 270th St Carroll IA 51401 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-05 |
Doug Ferneding |
dougferneding@gmail.com |
Carroll |
Iowa |
Iowa |
Jaynie Ferneding |
Brenda Klein |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Doug Ferneding |
dougferneding@gmail.com |
same |
Carroll |
Iowa |
Iowa |
Jaynie Ferneding |
Brenda Klein |
Signed |
1723 |
2023-07-06 11:50 |
Anonymous (not verified) |
94.188.205.175 |
Doug Ferneding |
Proprietorship |
21618 270th St. Carroll, IA 51401 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-06 |
Doug Ferneding |
dougferneding@gmail.com |
Carroll |
Carroll |
Iowa |
Brenda Klein |
Kyle Klein |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Doug Ferneding |
dougferneding@gmail.com |
same |
Carroll |
Carroll |
Iowa |
Brenda Klein |
Kyle Klein |
Signed |
1533 |
2023-03-25 10:24 |
Anonymous (not verified) |
94.188.207.226 |
Doug Uridil |
Proprietorship |
616 16th Street NE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-22 |
Doug Uridil |
douguridil@gmail.com |
Cedar Rapids |
United States |
IOWA |
Heidi Vincent |
Molly Coffman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Doug Uridil |
douguridil@gmail.com |
Self |
Cedar Rapids |
United status |
IOWA |
Heidi Vincent |
Molly Kaufman |
Signed |
1703 |
2023-06-23 08:58 |
Anonymous (not verified) |
94.188.205.175 |
Then & Kramer Construction, Inc |
Partnership |
P.O. Box 283 - Epworth, IA 52045 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-22 |
Shannon Kramer |
dparsons@english-insurance.com |
Epworth |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
self |
Dyersville |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
1704 |
2023-06-23 09:00 |
Anonymous (not verified) |
94.188.205.166 |
THen & Kramer Construcion, Inc. |
Partnership |
P.O. Box 283 - Epworth, IA 52045 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-22 |
Dakota Kramer |
dparsons@english-insurance.com |
Epworth, |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
self |
Dyersville |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
2128 |
2024-03-29 09:52 |
Anonymous (not verified) |
94.188.207.228 |
Mason Quality and Sons LLC |
Proprietorship |
18921 Willow St Omaha Ne 68136 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-29 |
Joel Castillo |
drake.centurion@gmail.com |
Omaha |
Douglas |
Nebraska |
Drake Rapaich |
Sunita Rapaich |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joel Castillo |
drake.centurion@gmail.com |
self |
Omaha |
Douglas |
Nebraska |
Drake Rapaich |
Sunita Rapaich |
Signed |
2123 |
2024-03-28 10:42 |
Anonymous (not verified) |
94.188.207.229 |
J&J Masonry |
Proprietorship |
2519 Poppleton 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. |
2024-03-28 |
Jose Marroquin |
drakkarhr7@gmail.com |
Omaha |
Douglas |
Nebraska |
Drake Rapaich |
Sunita Rapaich |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Marroquin |
drakkarhr7@gmail.com |
Self |
Omaha |
Douglas |
Nebraska |
Drake Rapaich |
Sunita Rapaich |
Signed |
333 |
2020-12-05 08:57 |
Anonymous (not verified) |
173.25.143.97 |
Groen Pediatric Consulting |
Limited Liability Company |
1206 NE 31ST ST 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. |
2021-01-01 |
Amy Groen |
dramygroen@yahoo.com |
Ankeny |
Iowa |
United States |
Daniel Martin |
Anita Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Amy Groen |
dramygroen@yahoo.com |
self |
Ankeny |
Iowa |
United States |
Kay Martin |
Priscilla Putzier |
Signed |
2219 |
2024-05-10 10:20 |
Anonymous (not verified) |
94.188.207.228 |
Froyo To Go, LLC |
Limited Liability Company |
909 4th Ave. South, Denison, Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-10 |
Derek Lambert |
drdereklambert@gmail.com |
Denison |
Crawford |
Iowa |
Maria Sandoval |
Nahomy Fernandez Alvarado |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Trevis Beeck |
trevis.beeck.u0ms@statefarm.com |
I am the State Farm Agent who is submitting the Business Policy |
Denison |
Crawford |
Iowa |
Maria Sandoval |
Nahomy Fernandez Alvarado |
Signed |
1337 |
2022-10-17 13:07 |
Anonymous (not verified) |
173.23.251.188 |
Dr. Dom Home Repair LLC |
Limited Liability Company |
503 Cedar Ave, Woodward IA. 50276 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-17 |
Dominique Forest |
drdomhomerepair@gmail.com |
Woodward |
Dallas |
Iowa |
Tara Murphy |
Mike Ryerson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dominique L Forest |
drdomhomerepair@gmail.com |
Owner/operator |
Woodward |
Dallas |
Iowa |
Tara Murphy |
Marc Badeaux |
Signed |
2131 |
2024-04-02 10:28 |
Anonymous (not verified) |
94.188.205.168 |
Driskell Spray, LLC |
Limited Liability Company |
1279 300th Ave Sidney, IA 51652 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-22 |
Jamie Driskell |
driskell216@gmail.com |
Sidney |
Fremont |
Iowa |
Melinda Goy |
Rhett Goy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jamie Driskell |
driskell216@gmail.com |
owner |
Sidney |
Fremont |
Iowa |
Melinda Goy |
Rhett Goy |
Signed |
125 |
2020-04-20 19:01 |
Anonymous (not verified) |
67.22.196.182 |
Driven School of Driving |
Limited Liability Company |
451 E 1st ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-20 |
Justin J. Franken |
drivenschoolofdriving@gmail.com |
Sioux Center |
Sioux |
IA |
Robyn Franken |
Gracyn Franken |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Franken |
drivenschoolofdriving@gmail.com |
Me |
Sioux Center |
Sioux |
IA |
Robyn Franken |
Gracyn Franken |
Signed |
838 |
2022-01-13 17:53 |
Anonymous (not verified) |
67.212.111.166 |
Cory's Painting LLC |
Limited Liability Company |
Po Box 1161 Cedar Falls, Iowa 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-13 |
Darren Dean Fanning |
dschmanning@gmail.com |
Cedar Falls |
Black Hawk County |
Iowa |
Kari Houle |
Braden L Gray |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cory Allen Koger |
coryspainting@gmail.com |
Self |
Cedar Falls |
Black Hawk County |
Iowa |
Kari Houle |
Braden L Gray |
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 |
1713 |
2023-06-27 09:06 |
Anonymous (not verified) |
94.188.205.175 |
Ray's Painters, LLC |
Limited Liability Company |
4120 Mount Alpine Street, Dubuque, IA 52001 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-15 |
Danny Sexton |
dsexton766@gmail.com |
Dubuque |
Dubuque |
Iowa |
Donna Gotto |
Brenda Lewis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ray's Painters LLC |
dsexton766@gmail.com |
insured |
Dubuque |
Dubuque |
Iowa |
Donna Gotto |
Brenda Lewis |
Signed |
1590 |
2023-04-21 07:10 |
Anonymous (not verified) |
94.188.205.168 |
Diamond Spray Foam & Coatings LLC |
Limited Liability Company |
19024 345th St, Forest City, IA 50436 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-21 |
Joshua G Diamond |
dsfinsulation@gmail.com |
Forest City |
Iowa |
United States |
Greg Diamond |
Renee Diamond |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua G Diamond |
dsfinsulation@gmail.com |
Owner |
Forest City |
Iowa |
United States |
Greg Diamond |
Renee Diamond |
Signed |
1665 |
2023-05-27 17:41 |
Anonymous (not verified) |
94.188.205.175 |
Diamond Spray Foam and Coatings LLC |
Limited Liability Company |
19024 345th St, Forest City, IA 50436 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-27 |
Joshua Gregory Diamond |
dsfinsulation@gmail.com |
Forest City |
Winnebago |
IA |
Brett Busenitz |
Bret Guggisburg |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua Gregory Diamond |
dsfinsulation@gmail.com |
Owner |
Forest City |
Winnebago |
IA |
Brett Busenitz |
Bret Guggisburg |
Signed |
1060 |
2022-04-19 15:08 |
Anonymous (not verified) |
64.186.23.83 |
CORRECTIONVILLE GOLF CLUB, INC |
Limited Liability Company |
1300 HACKBERRY STREET, CORRECTIONVILLE IOWA 51016 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-19 |
ADAM KELLY |
dslkraz@gmail.com |
CORRECTIONVILLE |
WOOD |
IWOA |
CANDACE |
AMBER HANSEN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KATIE EDWARDS |
kedwards@fnbcorrectionville.com |
SEC/TREASURER |
CORRECTIONVILLE |
WOODBURY |
IOWA |
CANDACE JACOBSON |
AMBER HANSEN |
Signed |
1567 |
2023-04-12 10:01 |
Anonymous (not verified) |
94.188.205.177 |
Hearts on fire llc |
Limited Liability Partnership |
931 14th Ave Se Altoona Iowa 50009 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-12 |
Matt Moffet |
dsm@fibrenew.com |
Altoona |
Polk |
Iowa |
Jason McDowell |
Mike Wennekamp |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matt Moffet |
dam@fibrenew.com |
Owner |
Altoona |
Polk |
Iowa |
Jason McDowell |
Mike Wennekamp |
Signed |
1156 |
2022-06-15 18:25 |
Anonymous (not verified) |
173.18.137.166 |
Talaska Trucking |
Proprietorship |
1626 byron ave. waterloo iowa 50702 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-15 |
Don Talaska |
dtalaska83@gmail.com |
WATERLOO |
Black Hawk |
Iowa |
Traci Talaska |
Reese Talaska |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Don Talaska |
dtalaska83@gmail.com |
Owner |
WATERLOO |
Black Hawk |
iowa |
Traci Talaska |
Reese Talaska |
Signed |
913 |
2022-02-14 18:50 |
Anonymous (not verified) |
72.25.23.147 |
Teimer Trucking |
Limited Liability Company |
3277 102nd St. Durant, IA 52747 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-14 |
Daniel Dennis Treimer |
dtreimer65@gmail.com |
Tipton |
Cedar |
Iowa |
Barry Boll |
Jennifer Treimer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Dennis Treimer |
dtreimer65@gmail.com |
Owner |
Tipton |
Cedar |
Iowa |
Barry Boll |
Jennifer Treimer |
Signed |
1803 |
2023-08-15 19:03 |
Anonymous (not verified) |
94.188.207.224 |
Teimer Trucking LLC |
Limited Liability Company |
3277 102nd St. Durant, IA 52747-9524 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-15 |
Daniel Dennis Treimer |
dtreimer65@gmail.com |
Tipton |
Iowa |
United States |
Spencer Lea Parsons |
Sydney Rae Lane |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Dennis Treimer |
dtreimer65@gmail.com |
Self |
Tipton |
Iowa |
United States |
Spencer Lea Parsons |
Sydney Rae Lane |
Signed |
1808 |
2023-08-17 17:17 |
Anonymous (not verified) |
94.188.205.168 |
Treimer Trucking LLC |
Limited Liability Company |
3277 102nd St. Durant, IA 52747-9524 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-17 |
Daniel Dennis Treimer |
dtreimer65@gmail.com |
Tipton |
Iowa |
United States |
Sydney Rae Lane |
Spencer Lea Parsons |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Dennis Treimer |
dtreimer65@gmail.com |
Self |
Tipton |
Iowa |
United States |
Syndey Rae Lane |
Spencer Lea Parsons |
Signed |
932 |
2022-02-22 17:20 |
Anonymous (not verified) |
72.212.49.250 |
Duane Bruxvoort |
Proprietorship |
201 Park Lane, Pella, IA 50219 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-01 |
Duane L Bruxvoort |
duanebrux@gmail.com |
Pella |
Marion |
Iowa |
Megan Lee Pingel |
Dorothy Jean Bruxvoort |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Duane Bruxvoort |
duanebrux@gmail.com |
Self |
Pella |
Marion |
Iowa |
Megan Lee Pingel |
Dorothy Bruxvoort |
Signed |
587 |
2021-07-26 12:40 |
Anonymous (not verified) |
172.56.7.208 |
Central Iowa Dict Cleaning |
Proprietorship |
1414 Adventureland Dr #4206 Altoona IA 50009 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-26 |
Gary Gallagher |
ductclean@gmail.com |
Altoona |
Polk |
IA |
Meghan Militti |
Todd Nastase |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gary Gallagher |
ductclean@gmail.com |
Self |
Altoona |
Polk |
IA |
Meghan Militti |
Todd Nastase |
Signed |
1919 |
2023-11-21 14:11 |
Anonymous (not verified) |
94.188.207.227 |
Refined Construction |
Limited Liability Company |
4148 Mattern ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-21 |
Dustin Martin |
dudtin.martin106@gmail.com |
Des Moines |
Polk |
IA |
Kelsey Baldinelli |
Brandi Martin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Martin |
dustin.martin106@gmail.com |
Sole officer |
Des Moines |
Polk |
IA |
Kelsey Baldinelli |
Brandi Martin |
Signed |
1602 |
2023-04-25 20:10 |
Anonymous (not verified) |
94.188.207.228 |
Miguel D. |
Limited Liability Company |
1221 22nd st des moines ia |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-21 |
Miguel Duron |
Duron6478@gmail.com |
Des moines |
Polk |
Ia |
Uziel martinez |
Cesar jaz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Miguel Duron |
Diron6478@gmail.com |
Self |
Des moines |
Polk |
Iowa |
Uziel Martinez |
Cesar jaz |
Signed |
1372 |
2022-11-14 20:36 |
Anonymous (not verified) |
198.14.213.147 |
Accurate Grading, LLC |
Limited Liability Company |
1417 290th St Macksburg, IA 50155 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-14 |
Dustin A McVay |
dustin0980@gmail.com |
Macksburg |
IA |
United States |
Dustin A McVay |
Angela D McVay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin A McVay |
dustin0980@gmail.com |
Owner |
Macksburg |
United States |
Iowa |
Dustin A McVay |
Angela D McVay |
Signed |
591 |
2021-07-29 16:42 |
Anonymous (not verified) |
138.43.237.95 |
Choice Ag Services INC |
Proprietorship |
1841 Firefly Rd, Manchester, IA 52057 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-29 |
Dustin Fessler |
dustin@choiceagservices.com |
Manchester |
IA |
United States |
Josh Soppe |
Adam Reth |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Fessler |
dustin@choiceagservices.com |
Owner |
Manchester |
Delaware |
Iowa |
Josh Soppe |
Adam Reth |
Signed |
2086 |
2024-03-08 19:11 |
Anonymous (not verified) |
94.188.207.223 |
Handyman & More |
Limited Liability Company |
1214 Lindwood Drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-08 |
Dustin allen Bergman |
dustinbergman86@gmail.com |
Carter Lake |
IA |
United States |
Reesa Edie |
Douglas Scadin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin allen Bergman |
dustinbergman86@gmail.com |
Owner of company |
Carter Lake |
IA |
United States |
Reesa Edie |
Douglas Scadin |
Signed |
573 |
2021-07-14 09:12 |
Anonymous (not verified) |
166.181.83.201 |
Dustin Demoss |
Proprietorship |
407 mechanic st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-13 |
Dustin Michael DeMoss |
dustindemoss14@gmail.com |
Monmouth |
Iowa |
United States |
Jake |
Jake |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Michael DeMoss |
dustindemoss14@gmail.com |
Idk |
Monmouth |
Iowa |
United States |
Jake |
Jake |
Signed |
2120 |
2024-03-27 15:31 |
Anonymous (not verified) |
94.188.205.169 |
Dustin pleshe |
Proprietorship |
6855 woodland ave unit 505 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-27 |
Dustin Pleshe |
dustinjpleshe@gmail.com |
WEST DES MOINES |
Iowa |
United States |
Kasey Cunningham |
Kathy Cunningham |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Pleshe |
dustinjpleshe@gmail.com |
He is me |
WEST DES MOINES |
Iowa |
United States |
Kasey cunningham |
Kathy cunningham |
Signed |
733 |
2021-11-09 15:35 |
Anonymous (not verified) |
50.83.182.182 |
United Trades Group LLC |
Limited Liability Company |
4813 Candlewick Drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-09 |
Dustin Kohler |
dustink@unitedtradesgroup.org |
Des Moines |
Polk |
Iowa |
Ryan Drabek |
Trevor Spidle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tory Webb |
torywebbdmi@gmail.com |
Owner, Management |
Norwalk |
Warren |
Iowa |
Ryan Drabek |
Trevor Spidle |
Signed |
627 |
2021-08-31 16:12 |
Anonymous (not verified) |
173.18.16.129 |
D's Home Improvement |
Limited Liability Company |
665 27th St Des Moines IA 50312 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-31 |
Dustin Mitchell |
dustinmitchell8855@gmail.com |
Des Moines |
Polk |
Iowa |
Lesa Reeves |
Kelly Coluzzi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Mitchell |
dustinmitchell8855@gmail.com |
Owner |
Des Moines |
Polk |
IA |
Lesa Reeves |
Kelly Coluzzi |
Signed |
894 |
2022-02-04 11:18 |
Anonymous (not verified) |
152.117.105.90 |
Dusty schraceo |
Proprietorship |
712 E 15th St Davenport, IA, 52803 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-04 |
Dusty Schraceo |
dustyschraceo1999@gmail.com |
Davenport |
Scott |
Iowa |
Tiffani Branham |
Cody Dunbar |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dusty Schraceo |
dustyschraceo1999@gmail.com |
Self |
Davenport |
Scott |
Iowa |
Tiffani Branham |
Cody Dunbar |
Signed |
637 |
2021-09-10 15:15 |
Anonymous (not verified) |
204.155.61.217 |
Duwa Waterproofing LLC |
Limited Liability Company |
1548 150th Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-10 |
Stacy Duwa |
duwawaterproofing@gmail.com |
Mt Pleasant |
Henry |
Iowa |
Jeffrey Spenner |
Shawn Powell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stacy Duwa |
duwawaterproofing@gmail.com |
owner |
Mt Pleasant |
Henry |
Iowa |
Jeffrey Spenner |
Shawn Powell |
Signed |
949 |
2022-03-04 16:09 |
Anonymous (not verified) |
173.20.147.171 |
Duwa Waterproofing LLC |
Limited Liability Company |
729 Deer view Ave, 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. |
2022-03-04 |
Stacy Duwa |
duwawaterproofing@gmail.com |
Tiffin |
Johnson |
Iowa |
Lauren Obermann |
Don Vittetoe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stacy Duwa |
duwawaterproofing@gmail.com |
owner |
Tiffin |
Johnson |
Iowa |
Lauren Obermann |
Don Vittetoe |
Signed |
954 |
2022-03-08 11:07 |
Anonymous (not verified) |
174.192.138.191 |
Duwa Waterproofing |
Limited Liability Company |
729 Deer View Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-08 |
Stacy Duwa |
duwawaterproofing@gmail.com |
Tiffin |
Johnson |
Iowa |
Chad Cooper |
Curtis Sexton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stacy Duwa |
duwawaterproofing@gmail.com |
President |
Tiffin |
Johnson |
Iowa |
Chad Cooper |
Curtis Sexton |
Signed |
785 |
2021-12-09 09:15 |
Anonymous (not verified) |
174.198.75.71 |
Daniel Vega camacho |
Proprietorship |
2415 river ,meadows drive Des Moines Iowa 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-09 |
Daniel Vega camacho |
dvega50265@gmail.com |
Des Moines |
Polk |
Iowa |
Chad Smith |
Adam Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Vega camacho |
dvega50265@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Chad Smith |
Adam Smith |
Signed |
1171 |
2022-06-24 09:40 |
Anonymous (not verified) |
65.125.92.130 |
Vega's Pro Painting, LLC |
Limited Liability Company |
2415 River Meadows Dr. Des Moines, IA 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-24 |
Daniel Vega Camacho |
dvega50265@gmail.com |
Des Moines |
Polk |
IA |
Chad Smith |
Adam Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Vega Camacho |
dvega50265@gmail.com |
Self |
Des Moines |
Polk |
IA |
Chad Smith |
Adam Smith |
Signed |
1959 |
2023-12-15 13:32 |
Anonymous (not verified) |
94.188.205.169 |
DeFreeceBuilt LLC |
Limited Liability Company |
216 Rellim Dr 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. |
2023-12-15 |
Dylan DeFreece |
dylan@defreecebuiltia.com |
Norwalk |
Warren |
Iowa |
Abigail DeFreece |
Ricki Schroeder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dylan DeFreece |
dylan@defreecebuiltia.com |
N/A |
Norwalk |
Warren |
Iowa |
Abigail DeFreece |
Ricki Schroeder |
Signed |
818 |
2022-01-02 11:34 |
Anonymous (not verified) |
184.94.130.66 |
dylan nelson trucking llc |
Limited Liability Company |
2011 465th street hanley falls mn 56245 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-02 |
dylan nelson |
dylancvi@gmail.com |
hanley falls mn |
yellow medicine |
mn |
derek verhelst |
mike fales |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
dylan nelson |
dylancvi@gmail.com |
owner |
hanley falls mn |
yellow medicine |
mn |
derek verhelst |
mike fales |
Signed |
105 |
2020-03-27 12:15 |
Anonymous (not verified) |
174.219.134.4 |
Elijah Willier |
Proprietorship |
805 SE 15th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-27 |
Elijah Willier |
e.willier42798@gmail.com |
Grimes |
Polk |
IA |
Isaac Willier |
Isaiah Willier |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Elijah Willier |
e.willier42798@gmail.com |
Self/ sole proprietor |
Grimes |
Polk |
IA |
Isaac Willier |
Isaiah Willier |
Signed |
1232 |
2022-07-28 18:27 |
Anonymous (not verified) |
50.83.189.149 |
Eagle Construction Co LLC |
Limited Liability Company |
1150 county line rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-28 |
Carlos Flores |
eagleconstruciontco.865@gmail.com |
Des Moines |
Warren |
Iowa |
Morgan Conrard |
Ronika Htu |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Carlos Flores |
eagleconstruciontco.865@gmail.com |
Owner |
Des Moines |
Warren |
IA |
Morgan Conrard |
Ronika Htu |
Signed |
1712 |
2023-06-26 20:33 |
Anonymous (not verified) |
94.188.205.167 |
Eastern Iowa Overhead Door |
Proprietorship |
120 N Eliza Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-26 |
Tim Chapin |
easterniadoor@gmail.com |
Maquoketa |
IA |
United States |
Carri Lee Waack |
Wendy Marie Zaruba |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tim Chapin |
easterniadoor@gmail.com |
Owner |
Maquoketa |
Jackson |
United States |
Carri Lee Waack |
Wendy Marie Zaruba |
Signed |
834 |
2022-01-12 17:34 |
Anonymous (not verified) |
67.212.111.166 |
Cory's Painting LLC |
Limited Liability Company |
Po Box 1161 Cedar Falls, Iowa 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-13 |
Erik Bjorn Nelson |
ebjornnelson@gmail.com |
Waterloo |
Black Hawk County |
Iowa |
Kari Houle |
Steven John Swanson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cory Koger |
coryspainting@gmail.com |
Self |
Cedar Falls |
Black Hawk County |
Iowa |
Kari Houle |
Steven John Swanson |
Signed |
778 |
2021-12-05 11:39 |
Anonymous (not verified) |
71.34.165.66 |
Perfection heating and Plumbing LLC |
Limited Liability Company |
2522 3 Ave SW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-05 |
Edward William cooper |
ecooper@amermech.com |
Altoona |
Polk |
IA |
Lindsay cooper |
Edward cooper SR |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Eddie Cooper |
ecooper@amermech.com |
Self |
Altoona |
Polk |
IA |
Lindsay cooper |
Edward cooper SR |
Signed |
1211 |
2022-07-18 14:10 |
Anonymous (not verified) |
172.58.85.43 |
Palomeque Gutter LLC |
Limited Liability Company |
2004 se 24th st Grimes IA 50111 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-18 |
Philips Palomeque |
ecuaphilips94@gmail.com |
Des Moines IA |
USA |
Iowa |
Philips Peter Palomeque Vallejo |
Philips Palomeque |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Philips Palomeque |
ecuaphilips94@gmail.com |
Owner |
Des Moines |
USA |
Iowa |
Philips Peter Palomeque Vallejo |
Erika Zapata |
Signed |
1547 |
2023-03-30 08:45 |
Anonymous (not verified) |
94.188.207.223 |
Palomeque Gutter LLC |
Limited Liability Company |
2004 SE 24TH ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-30 |
Philips Palomeque |
ecuaphilips94@gmail.com |
Grimes |
USA |
IA |
Philips Palomeque |
Philips Palomeque |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Philips Palomeque |
ecuaphilips94@gmail.com |
My self |
Grimes |
USA |
Ia |
Philips Palomeque |
Philips Palomeque |
Signed |
1727 |
2023-07-07 18:26 |
Anonymous (not verified) |
94.188.205.169 |
D&E LLC DBA Kanesville Valley |
Limited Liability Company |
P.O. Box 337 Council Bluffs, IA, 51502 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-07 |
Edward Gregory |
eddegregory@gmail.com |
Council Bluffs |
Pottawattamie |
Iowa |
Natasha Gregory |
Stanley Gregory |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Edward Gregory |
eddegregory@gmail.com |
Self |
Council Bluffs |
Pottawattamie |
Iowa |
Natasha Gregory |
Stanley Gregory |
Signed |