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Nonelection of Workers' Compensation or Employers' Liability Coverage

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# Submitted User IP address Name of Employer: Type of Entity: Address of Employer's Home Office: Statement 1 Agreement: Statement 2 Agreement: Statement 3 Agreement: Understanding Confirmation: Check Either Alternative (1) or (2): Date: Full Name of Individual: Email: City of Residence: County of Residence: State of Residence: Full Name of Witness 1: Full Name of Witness 2: Signing Indication: Check either alternative (1) or (2): Full Name of Authorized Agent: Email of Authorized Agent: Relationship to Employer of Authorized Agent: City of Residence: County of Residence: State of Residence: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Indication:
211 2020-07-20 15:30 Anonymous (not verified) 138.43.237.249 High Caliber Fiber Limited Liability Company 2958 110th Ave Masonville IA 50654 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-20 Chris Chris_cooepr@highcaliberfiber.com masonville Delaware IA NIck Beranek Nicole KIntzle Signed (1) The employer does not elect the employers’ liability coverage. Chris Cooper Chris_cooper@highcaliberfiber.com Self Masonville Delaware IA Nick Beranek Nicole Kintzle 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
185 2020-06-12 14:50 Anonymous (not verified) 173.28.28.57 Aaron & Eliesa Thomas Partnership 706 3rd Avenue, Parkersburg IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-20 Aaron & Eliesa Thomas cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Aaron & Eliesa Thomas cmins_re@mchsi.com Self Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed
1358 2022-11-03 23:03 Anonymous (not verified) 172.86.32.251 LeafFilter North LLC Limited Liability Company 1020 James Drive Suite A | Hartland, WI 53209 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-03 Aaron Bensinger guttershereandnow@outlook.com Marion Linn Iowa Silvena Cammareri Aaron Bensinger Signed (1) The employer does not elect the employers’ liability coverage. Aaron Bensinger guttershereandnow@outlook.com Self Marion Linn Iowa Aaron Bensinger Silvena Cammareri Signed
630 2021-09-01 19:29 Anonymous (not verified) 97.125.133.79 Aaron J. Rosenbaum Proprietorship 2005 Pine St, Granger, IA 50109 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-01 Aaron J. Rosenbaum aabaum7@gmail.com Granger Dallas Iowa Bruce Klinkenberg Trudy Rosenbaum Signed (1) The employer does not elect the employers’ liability coverage. Aaron Rosenbaum aabaum7@gmail.com self Granger Dallas Iowa Bruce Klinkenberg Trudy Rosenbaum Signed
1382 2022-12-07 14:40 Anonymous (not verified) 96.31.1.206 IGL RENTAL LLC Limited Liability Company PO BOX 317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-25 AARON JONES STAYBOJI@GMAIL.COM ARNOLDS PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. AARON JONES STAYBOJI@GMAIL.COM SELF ARNOLDS PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
376 2021-01-26 11:14 Anonymous (not verified) 173.28.210.45 Cross Medical Lab, L.L.P Limited Liability Partnership 500 E Market St Iowa City IA 52240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-26 Aaron Klein lhavel_23@gmail.com Iowa City Johnson Iowa Ashley Lee Dan Wegman Signed (1) The employer does not elect the employers’ liability coverage. Lori Havel lhavel_23@gmail.com Office Manager Iowa CIty Johnson IA Ashley Lee Dan Wegman Signed
561 2021-07-08 09:11 Anonymous (not verified) 66.188.136.150 Aaron Maldonado dba ATM Trucking Proprietorship 1011 Reynolds Drive, Charleston, IL 61920 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-07 Aaron Maldonado dba ATM Trucking kschumacher@tricorinsurance.com Charleston Coles IL Mitch Kemp Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Aaron Maldonado dba ATM Trucking kschumacher@tricorinsurance.com Same Charleston Coles IL Mitch Kemp Shuree Behr Signed
230 2020-08-13 16:59 Anonymous (not verified) 174.217.21.76 Aaron Gilbert Proprietorship 11864 W 125th St S, Runnells, IA 50237 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-13 Aaron Michael Gilbert gilbertinpc@msn.com Runnells Jasper Iowa Bob Coluzzi Mitch Coluzzi Signed (1) The employer does not elect the employers’ liability coverage. Aaron Michael Gilbert gilbertinpc@msn.com Same person Runnells Jasper Iowa Bob Coluzzi Mitch Coluzzi Signed
1031 2022-04-05 06:47 Anonymous (not verified) 172.58.83.170 Aaron Soboroff Limited Liability Company 1617 w George Washington Blvd Davenport Iowa 52804 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-05 Aaron P Soboroff Treedr47@gmail.com Davenport Scott Iowa Amanda Isenberg Josh Strother Signed (1) The employer does not elect the employers’ liability coverage. Aaron P Soboroff Treedr47@gmail.com Owner Always Mowing Davenport Scott Iowa Amanda Isenberg Josh Strother Signed
479 2021-04-14 14:58 Anonymous (not verified) 65.103.82.36 Aaron Smart Limited Liability Partnership 6064 227th st. albia IA 52531 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-01 Aaron Smart nonegiven@email.com Albia Monroe IA Emily Jordan Signed (1) The employer does not elect the employers’ liability coverage. Aaron Smart nonegiven@email.com partner Albia Monroe IA Emily Jordan Signed
215 2020-07-27 13:45 Anonymous (not verified) 173.28.28.57 Main Street Printing & Design, LLC Limited Liability Company 706 3rd Avenue, Parkersburg IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-09 Aaron Thomas cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Aaron Thomas cmins_re@mchsi.com Self Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed
113 2020-04-07 12:30 Anonymous (not verified) 173.27.33.108 Aarron Alley Proprietorship 101 S Teale St. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2018-05-15 Aarron Alley aarronalley10@yahoo.com Davis City Decatur Iowa Joe Fitzgerald Steve Young Signed (1) The employer does not elect the employers’ liability coverage. Aarron Alley aarronalley10@yahoo.com Owner Davis City Decatur Iowa Joe Fitzgerald Steve Young Signed
308 2020-11-08 09:17 Anonymous (not verified) 173.27.33.108 Aarron Alley Proprietorship 101 S Teale St. Davis City, IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-11-01 Aarron Alley aarronalley10@yahoo.com Davis City Decatur Iowa Joe Fitzgerald Steve Young Signed (1) The employer does not elect the employers’ liability coverage. Aarron Alley aarronalley10@yahoo.com Owner Davis City Decatur Iowa Joe Fitzgerald Steve Young Signed
81 2020-02-25 17:31 Anonymous (not verified) 66.43.239.175 Lynx Ag LLC Limited Liability Company 510 H Ave, Churdan IA 50050 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-25 Abby Glendenning lanceandabby@wccta.net Churdan Greene Iowa Dena M. Anderson Shelly Brus Signed (1) The employer does not elect the employers’ liability coverage. Lance Glendenning lanceandabby@wccta.net President Churdan Greene IA Dena M Anderson Shelly Brus Signed
972 2022-03-14 18:01 Anonymous (not verified) 207.32.37.48 Lynx Ag LLC Limited Liability Company 510 H Ave, Churdan, IA 50050 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-14 Abby Glendenning lanceandabby@wccta.net Churdan Greene Iowa Kim Kersey Shelly Brus Signed (1) The employer does not elect the employers’ liability coverage. Lance Glendenning lanceandabby@wccta.net President Churdan Greene Iowa Kim Kersey Shelly Brus Signed
1255 2022-08-15 11:18 Anonymous (not verified) 173.215.77.92 Abby Snyder Design LLC Limited Liability Company 1540 SE Greenbriar Circle, Waukee, IA 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-15 Abby Mae Snyder abby.mae.snyder@gmail.com Waukee Dallas Iowa Jenni Wiig Katy Hildman Signed (1) The employer does not elect the employers’ liability coverage. Abby Mae Snyder abby.mae.snyder@gmail.com Self Waukee Dallas Iowa Jenni Wiig Katy Hildman Signed
791 2021-12-14 11:35 Anonymous (not verified) 108.178.194.186 Leaf Home solutions LLC Limited Liability Company 1595 Georgetown rd. Hudson OH 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. 2023-12-14 Abelardo Lino Montes alinomontes@gmail.com Le claire IA 52753 Scott Iowa Ann Pelton Herman Roche Signed (1) The employer does not elect the employers’ liability coverage. Abelardo Lino Montes alinomontes@gmail.com Owner Le Claire Scott IA Ann Pelton Herman Roche Signed
418 2021-03-03 13:50 Anonymous (not verified) 173.215.42.12 Lynx Ag LLC Limited Liability Company 510 H Ave, Churdan IA 50050 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-03 Abigail Jayne Glendenning lanceandabby@wccta.net Churdan Greene Iowa Shelly L. Brus Dena M. Anderson Signed (1) The employer does not elect the employers’ liability coverage. Lance Jeffrey Glendenning lanceandabby@wccta.net President Churdan Greene Iowa Shelly L. Brus Dena M. Anderson Signed
68 2020-02-19 12:00 Anonymous (not verified) 198.14.241.59 SIERRA ROOFING LLC Limited Liability Company 909 N ELM ST WEST LIBERTY IA 52776 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-19 ABRAHAM GRANJENO SIERRA89@GMAIL.COM WEST LIBERTY MUSCATINE IOWA JOSE SALGADO ALEJANDRIA FRAUSTO Signed (1) The employer does not elect the employers’ liability coverage. ABRAHAM GANJENO SIERRA89@GMAIL.COM OWNER WEST LIBERTY MUSCATINE IOWA JOSE SALGADO ALEJANDRIA FRAUSTO Signed
1050 2022-04-14 14:55 Anonymous (not verified) 173.18.22.217 L & L Home Solutions Limited Liability Company 3909 sw 14th st DSM 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. 2022-04-14 Abraham LaMark landlhs@gmail.com des moines Polk IA Jen Lambert william schuldt Signed (1) The employer does not elect the employers’ liability coverage. Abraham LaMark landlhs@gmail.com friend des moines polk IA Jen LAmbert william schuldt Signed
476 2021-04-13 19:23 Anonymous (not verified) 173.31.147.225 COAST TO COAST MILLWRIGHT LLC Limited Liability Company 2909 HWY 71 AND 9 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. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-04-05 ADALBERTO CANTU JOEL@WALKERINSURANCEIA.COM SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. ADALBERTO CANTU janiecantu433@outlook.com SELF-MEMBER SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
1179 2022-07-05 12:21 Anonymous (not verified) 173.18.233.175 Crossline Contracting LLC Limited Liability Company 2009 Wilson Ave SW, Cedar Rapids, IA 52404 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-05 Adam Anderson crosslinecontracting319@gmail.com Ryan, IA Deleware Iowa Branden Peters Todd Philpott Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Crossline Contracting LLC crosslinecontracting319@gmail.com Self Ryan Iowa Deleware Iowa Branden Peters Todd Philpott Signed
1264 2022-08-16 21:22 Anonymous (not verified) 50.82.84.19 Nogotta Trucking LLC Limited Liability Company 16617 Wilden Dr, 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. 2022-08-16 Adam Dickinson nogottatruckingllc@gmail.com Clive IA United States Gary Dickinson Mike Martens Signed (1) The employer does not elect the employers’ liability coverage. Adam Dickinson nogottatruckingllc@gmail.com Managing Member Clive IA United States Gary Dickinson Mike Martens Signed
763 2021-11-22 12:32 Anonymous (not verified) 63.229.189.35 Adam Dotson Tiling Proprietorship 324 E 14th Street, Spencer, IA 51301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-22 Adam Dotson adamdotson1975@gmail.com Spencer Clay Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Adam Dotson adamdotson1975@gmail.com Self Spencer Clay Iowa Abigail Miles Alex Miles 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
1389 2022-12-11 12:36 Anonymous (not verified) 24.149.1.5 Project Fix It LLC Limited Liability Company 1303 Washington Street Cedar Falls 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. 2022-12-12 Adam L Reiter adam.reiter@projectfixit.net Cedar Falls IA United States Jennifer Reiter Logan Reiter Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Project Fix It adam.reiter@projectfixit.net Owner Cedar Falls IA United States Jennifer Reiter Logan Reiter Signed
1469 2023-02-19 18:23 Anonymous (not verified) 94.188.205.169 Superior Sheet Metal LLC Limited Liability Company 1819 MM Ave Marengo, IA 52301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-19 Adam Lynn Nielsen adamnielsen4@yahoo.com Marengo Iowa United States Emily Jean Nielsen Joseph Daryl Kriegel Signed (1) The employer does not elect the employers’ liability coverage. Adam Lynn Nielsen adamnielsen4@yahoo.com Self Marengo Iowa Iowa Emily Jean Nielsen Joseph Daryl Kriegel Signed
321 2020-11-17 10:26 Anonymous (not verified) 173.18.16.129 Adam Quimby Proprietorship 2033 10th Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-01 Adam Quimby adam.m.quimby@gmail.com Des Moines Polk Iowa Robert Coluzzi Kelly Coluzzi Signed (1) The employer does not elect the employers’ liability coverage. Adam Quimby adam.m.quimby@gmail.com Owner Des Moines Polk Iow Robert Coluzzi Kelly Coluzzi Signed
592 2021-07-29 16:44 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 Adam Reth adam@choiceagservices.com Manchester IA United States Josh Soppe Adam Reth Signed (1) The employer does not elect the employers’ liability coverage. Adam Reth adam@choiceagservices.com Owner Manchester Delaware Iowa Josh Soppe Dustin Fessler Signed
1612 2023-04-27 10:37 Anonymous (not verified) 94.188.207.223 Grind Works LLC Proprietorship 26416 289th place Unit H Adel IA 50003 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-27 Adam Samuelson Hello@grindworksia.com Adel Dallas Iowa Chandler Clark Adam Samuelson Signed (1) The employer does not elect the employers’ liability coverage. Adam Samuelson Hello@Grindowrksia.com N/A Adel Dallas Iowa Adam Samuelson Chandler Clark Signed
1231 2022-07-27 11:59 Anonymous (not verified) 108.217.146.87 Adam Towe Proprietorship 26 Reeves Rd Hartselle, AL 35640 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-27 Adam Towe adamtowe99@gmail.com Hartselle Morgan AL Lynn Cary Karen Gifford Signed (1) The employer does not elect the employers’ liability coverage. Hunter Flying Service hunterflying@att.net Owner Hunter AR United States Karen Gifford Jason White Signed
1619 2023-04-28 11:20 Anonymous (not verified) 94.188.207.224 Hunter Flying Service, LLC Limited Liability Company PO Box 215 Hunter, AR 72074 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-28 Adam Towe hunterflying@att.net Hartselle Morgan Alabama Ronnie Skinner Karen Gifford Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Lynn Cary hunterflying@att.net Owner Hunter Woodruff Arkansas Ronnie Skinner Karen Gifford Signed
1167 2022-06-23 09:56 Anonymous (not verified) 74.84.106.106 Adam Wamsher Proprietorship 1517 Ridge Crest Ct Knoxville, IA 50138 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-23 Adam Wamsher wamshera@hotmail.com Knoxville Marion Iowa Tina Owens Kim Owens Signed (1) The employer does not elect the employers’ liability coverage. Adam Wamsher wamshera@hotmail.com Self Knoxville Marion Iowa Tina Owens Kim Owens 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
1838 2023-09-12 10:48 Anonymous (not verified) 94.188.207.224 OKOBOJI TSHIRT CENTER LLC Limited Liability Company PO BOX 158 ARNOLDS PARK, IA 51331 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-12 ADIR SEBAN PACIFIC513@YAHOO.COM ARNOLDS PARK DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. ADIR SEBAN PACIFIC513@YAHOO.COM SELF ARNOLDS PARK DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1823 2023-08-29 12:46 Anonymous (not verified) 94.188.205.177 A&S Construction LLC Proprietorship 5920 Village Circle Johnston IA 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-28 Admir Omerovic sabinamur22@icloud.com 5920 Village Circle Polk IA Kelly Coluzzi Erick Schuldt Signed (1) The employer does not elect the employers’ liability coverage. Admir Omerovic sabinamu22@icloud.com Owner Johnston Polk IA Kelly Coluzzi Erick Schuldt Signed
510 2021-05-10 15:27 Anonymous (not verified) 108.190.5.14 Shift Transport LLC Limited Liability Company 4215 Kris Line 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. 2021-05-10 Adnan Pajazetovic Adoni.shift@gmail.com Waterloo Black Hawk Iowa Fata Pajazetovic Melda Pajazetovic Signed (1) The employer does not elect the employers’ liability coverage. Adnan Pajazetovic adoni.shift@gmail.com Owner Waterloo Black Hawk Iowa Fata Pajazetovic Melda Pajazetovic Signed
929 2022-02-18 09:18 Anonymous (not verified) 174.198.74.217 LA Painting LLC Limited Liability Company 6460 Merle Hay Rd unit 222 Johnston, IA 50131 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-18 Adolfo Rodriguez Afanador adolforodriguez11@yahoo.com Johnston Polk Iowa Esequiel Rodriguez Karina Valdez Signed (1) The employer does not elect the employers’ liability coverage. Adolfo Rodriguez Afanador adolforodriguez11@yahoo.com Owner Johnston Polk Iowa Esequiel Rodriguez Karina Valdez Signed
525 2021-05-18 09:42 Anonymous (not verified) 50.82.130.211 Adrian Bernard Proprietorship 803 Russell Circle, Parkersburg IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-07 Adrian Bernard cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Adrian Bernard cmins_re@mchsi.com Self Parkersburg Butler Iowa Chad Campbell Chad Campbell Signed
1863 2023-10-06 12:24 Anonymous (not verified) 94.188.207.223 ADRIAN CAZARES HERNANDEZ Proprietorship 409 N 16TH PL, ESTHERVILLE, IA 51334 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-06 ADRIAN CAZARES HERNANDEZ JOEL@WALKERINSURANCE.COM ESTHERVILLE EMMET IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. ADRIAN CAZARES HERNANDEZ JOEL@WALKERINSURANCEIA.COM SELF ESTHERVILLE EMMET IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
492 2021-04-22 08:33 Anonymous (not verified) 66.188.136.150 Adrian Hackney Proprietorship 1513 7th St. Boone, IA 50036 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-20 Adrian Hackney kschumacher@tricorinsurance.com Boone Boone IA Shuree Behr Mitch Kemp Signed (1) The employer does not elect the employers’ liability coverage. Adrian Hackney kschumacher@tricorinsurance.com Same Boone Boone IA Shuree Behr Mitch Kemp Signed
1927 2023-11-29 13:13 Anonymous (not verified) 94.188.207.228 Yaardman landscaping llc Limited Liability Company 51623 se seet 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. 2023-11-29 Adrian Pink Mr.Pink1118@gmail.com CEDAR RAPIDS IA United States Andrea Parker Kamar James Signed (1) The employer does not elect the employers’ liability coverage. Adrian Pink Mr.Pink1118@gmail.com Owner CEDAR RAPIDS IA United States Andrea Parker Kamar James Signed
1938 2023-12-05 11:54 Anonymous (not verified) 94.188.207.225 Genius automotive Limited Liability Company 51623 se seet 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. 2023-12-05 Adrian Pink Mr.Pink1118@gmail.com CEDAR RAPIDS IA United States Andrea Parker Kamar james Signed (1) The employer does not elect the employers’ liability coverage. Adrian Pink Mr.Pink1118@gmail.com None CEDAR RAPIDS IA United States Andrea Parker Kamar James Signed
1056 2022-04-18 12:04 Anonymous (not verified) 63.152.56.49 Milo’s Construction Limited Liability Company 8 Erobi ln Iowa city IA 52240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-18 Adriana Celis celisary0501@gmail.com Iowa city Johnson Iowa Arcelia Gómez Karina Beltrán Signed (1) The employer does not elect the employers’ liability coverage. Milo’s Construction celisary0501@gmail.com Owner Iowa city Johnson Iowa Arcelia Gómez Karina Beltrán Signed
1501 2023-03-07 11:27 Anonymous (not verified) 94.188.205.167 Adriene Dangler Proprietorship 2400 South Shore Dr Clear Lake, IA 50428 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-14 Adrienne Dangler darrele@ciains.biz Clear Lake Cerro Gordo Iowa Darrel Elsbernd Chris Fye Signed (1) The employer does not elect the employers’ liability coverage. Darrel Elsbernd darrele@ciains.biz agent Clear Lake Cerro Gordo Iowa Darrel Elsbernd Chris Fye Signed
1718 2023-06-29 12:36 Anonymous (not verified) 94.188.205.166 Aidan Obermueller Proprietorship 2520 N Grandview Avenue, 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. 2023-06-27 Aidan Obermueller aidanobermueller@icloud.com Dubuque Dubuque Iowa Brenda Lewis Sue Miller Signed (1) The employer does not elect the employers’ liability coverage. Aidan Obermueller aidanobermueller@icloud.com self Dubuque Dubuque Iowa Brenda Lewis Sue Miler Signed
307 2020-11-04 14:43 Anonymous (not verified) 50.82.130.211 ALL N DESIGNS, LLC Limited Liability Company 601 Nicklaus Drive, Parkersburg IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-23 Aimee Allan cmins_re@mchsi.com Parkersburg Butler iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Aimee Allan cmins_re@mchsi.com Self Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed
1550 2023-03-31 13:35 Anonymous (not verified) 94.188.205.177 Nadarevic Group LLC Limited Liability Company 3633 NW 177th 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. 2023-03-31 Ajdin Nadarevic ajdin@silverstonedevgroup.com Clive Dallas Iowa Jeremy Boysen Brooke Boysen Signed (1) The employer does not elect the employers’ liability coverage. Ajdin Nadarevic ajdin@silverstonedevgroup.com Owner Clive Dallas Iowa Jeremy Boysen Brooke Boysen Signed
1539 2023-03-28 16:50 Anonymous (not verified) 94.188.207.230 Sulzner Construction LLC Limited Liability Company 210 N CHERRY ST, PO BOX 264 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-28 Aksel C Sulzner akselsmoke@gmail.com Mechanicsville IA United States self self Signed (1) The employer does not elect the employers’ liability coverage. Aksel C Sulzner akselsmoke@gmail.com Self Mechanicsville IA United States self self Signed
1543 2023-03-29 15:37 Anonymous (not verified) 94.188.207.225 Sulzner Construction LLC Limited Liability Company 210 N CHERRY ST, PO BOX 264 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-29 Aksel C Sulzner akselsmoke@gmail.com Mechanicsville IA United States Toni Pollard Phil Rouse Signed (1) The employer does not elect the employers’ liability coverage. Aksel C Sulzner akselsmoke@gmail.com Self Mechanicsville IA United States Toni Pollard Phil Rouse Signed
1456 2023-02-15 13:12 Anonymous (not verified) 94.188.205.168 Bloodgood construction services Proprietorship 4422 happy trail prole ia 50229 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-15 Alan Dean bloodgood alanbloodgood@gmail.com Prole Warren Ia Derek bloodgood Albert bloodgood Signed (1) The employer does not elect the employers’ liability coverage. Bloodgood construction services alanbloodgood@gmail.com Self Prole Warren Ia Derek bloodgood Albert bloodgood Signed
1134 2022-05-31 09:08 Anonymous (not verified) 65.125.92.130 EAC Multi-Services, Inc, Proprietorship 6224 Forest Ave. Des Moines, IA 50311 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-31 Alan E Enamordo enriqueecalowcare@gmail.com Des Moines Polk Iowa Chad Smith Adam Smith Signed (1) The employer does not elect the employers’ liability coverage. Alan E Enamordo enriqueecalowcare@gmail.com self Des Moines Polk IA Chad Smith Adam Smith Signed
1166 2022-06-23 09:44 Anonymous (not verified) 74.84.106.106 alan squires Proprietorship 702 2nd ave sw #4 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-23 alan squires shanesq411@gmail.comm altoona polk iowa TIna Owens Rita Littell Signed (1) The employer does not elect the employers’ liability coverage. alan squires shanesq411@gmail.com self altoona polk iowa Tina Owens Rita Littell Signed
765 2021-11-22 16:07 Anonymous (not verified) 63.229.189.35 Stahmer Construction Proprietorship 318 Jackson St N Harris IA 51345 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-22 Alan Stahmer abigail@rickmilesartisans.com Harris Osceola Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Alan Stahmer abigail@rickmilesartisans.com Self Harris Osceola Iowa Abigail Miles Alex Miles Signed
87 2020-03-11 15:42 Anonymous (not verified) 50.105.78.41 Al's Aerial Spraying, LLC Limited Liability Company 3473 N Shepardsville Rd, Ovid MI 48866 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-11 Albert Edward Schiffer Al400@aol.com Ovid Cliinton Michigan Seth Alexander Nicholas Crofoot Signed (1) The employer does not elect the employers’ liability coverage. Albert Edward Schiffer Al400@aol.com Boss Ovid Clinto Michigan Nicholas Crofoot Nicholas Crofoot Signed
1937 2023-12-04 17:42 Anonymous (not verified) 94.188.205.174 Albert Schwartz Proprietorship 2250 Hwy 1 Sw Kalona, ia 52247 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-04 Albert Schwartz sageburnner100@msn.com Kalona Johnson Iowa Laura Schwartz Jackie Etheredge Signed (1) The employer does not elect the employers’ liability coverage. Albert Schwartz sageburnner100@msn.com Myself Kalona Johnson Iowa Laura Schwartz Jackie Etheredge Signed
487 2021-04-20 11:10 Anonymous (not verified) 207.191.193.167 Chento Construction Proprietorship 702 Lincoln St. Ainsworth, IA 52201 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-05 Alberto Garcia chentoconstruction@hotmail.com Ainsworth Washington Iowa Anthony Johnson Jessica Lopez Signed (1) The employer does not elect the employers’ liability coverage. Alberto Garcia chentoconstruction@hotmail.com Owner Ainsworth Washington Iowa Anthony Johnson Jessica Lopez Signed
1724 2023-07-06 19:34 Anonymous (not verified) 94.188.207.223 ALDO B. CANCINO HERNANDEZ Proprietorship 2524 SHADOW CREEK LN, DES MOINES, IA 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-06 ALDO B. CANCINO HERNANDEZ aldo94.cansino@gmail.com DES MOINES USA IOWA JUAN M. MAYORGA OFELIA BUSTILLOS VALENZUELA Signed (1) The employer does not elect the employers’ liability coverage. ALDO B. CANCINO HERNANDEZ aldo94.cancino@gmail.com SELF DES MOINES USA IOWA JUAN M. MAYORGA OFELIA BUSTILLOS VALENZUELA Signed
508 2021-05-10 11:56 Anonymous (not verified) 172.58.83.106 Aldo Monroy Limited Liability Company 201 Ne 44th St , Apt 111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-10 Aldo Monroy Aldogmonroy@gmail.com Ankeny Polk IOWA Aldo Monroy Elizabeth lopez Signed (1) The employer does not elect the employers’ liability coverage. Aldo Monroy Aldogmonroy@gmail.com Owner Ankeny Polk IOWA Aldo g monroy reyes Elizabeth tavarez lopez Signed
448 2021-03-25 10:18 Anonymous (not verified) 172.58.83.161 Limited Liability Company 201 Ne 44th St , Apt 111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-25 Aldo Monroy reyes Aldogmonroy@gmail.com Ankeny Polk county IOWA Elizabeth lopez Brayan monroy Signed (1) The employer does not elect the employers’ liability coverage. Aldo Monroy Aldogmonroy@gmail.com None Ankeny Polk county IOWA Aldo Monroy Brayan monroy Signed
1943 2023-12-06 16:34 Anonymous (not verified) 94.188.207.230 Your Neighbors Pressure Washing LLC Limited Liability Company 2059 Lyon St Des Moines Iowa 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-06 Alejandro Bacano Rodriguez alejandrobacanorodriguez@gmail.com Des Moines Polk Iowa Breny Rodriguez Gabriela Martinez Signed (1) The employer does not elect the employers’ liability coverage. Alejandro Bacano Rodriguez alejandrobacanorodriguez@gmail.com Myself Des Moines Polk Iowa Breny Rodriguez Gabriela Martinez Signed
1944 2023-12-06 16:41 Anonymous (not verified) 94.188.207.226 Sell Now Iowa Limited Liability Company 5525 Meredith Dr Suite B Des Moines, Iowa 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-06 Alejandro Bacano Rodriguez alejandrobacanorodriguez@gmail.com Des Moines Polk Iowa Breny Rodriguez Gabriela Martinez Signed (1) The employer does not elect the employers’ liability coverage. Sale Now Iowa team@sellnowiowa.com None Des Moines Polk Iowa Breny Rodriguez Gabriela Martinez Signed
1945 2023-12-06 16:47 Anonymous (not verified) 94.188.205.169 Sell Now Iowa Limited Liability Company 5525 Meredith Drive Suite B Des Moines Iowa 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-06 Alejandro Bacano Rodriguez alejandrobacanorodriguez@gmail.com Des Moines Polk Iowa Breny Rodriguez Gabriela Martinez Signed (1) The employer does not elect the employers’ liability coverage. Sell Now Iowa team@sellnowiowa.com None Des Moines Polk Iowa Breny Rodriguez Gabriela Martinez Signed
1946 2023-12-06 16:51 Anonymous (not verified) 94.188.205.168 Blue Sky Renovations Iowa LLC Limited Liability Company 2059 Lyon St Des Moines Iowa 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-06 Alejandro Bacano Rodriguez alejandrobacanorodriguez@gmail.com Des Moines Polk Iowa Breny Rodriguez Gabriela Martinez Signed (1) The employer does not elect the employers’ liability coverage. Sell Now Iowa team@sellnowiowa.com None Des Moines Polk Iowa Breny Rodriguez Gabriela Martinez Signed
1468 2023-02-17 16:17 Anonymous (not verified) 94.188.207.230 AJ Cook LLC Limited Liability Company 1817 Redbud Street, 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. 2023-02-17 Alejandro Cook alejandro.cook14@gmail.com Norwalk Warren Iowa Steve Bieghler Nichole Bishop Signed (1) The employer does not elect the employers’ liability coverage. Alejandro Cook alejandro.cook14@gmail.com Self Norwalk Warren Iowa Steve Bieghler Nichole Bishop Signed
390 2021-02-10 14:24 Anonymous (not verified) 173.24.190.134 King Excavation, LLC Limited Liability Company 5343 410th St, Cylinder IA 50528 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-03 Aletha King aletha1949@ncn.net Cylinder Palo Alto Iowa Candie Clark Dave Walters Signed (1) The employer does not elect the employers’ liability coverage. Aletha King aletha1949@ncn.net Member of LLC Cylinder Palo Alto Iowa Candie Clark Dave Walters Signed
1406 2023-01-04 11:58 Anonymous (not verified) 67.55.135.18 Duncan Home Services LLC Limited Liability Company 2543 Cottage 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. 2022-01-04 Alethea Anne Duncan projects@duncanhs.com Waverly IA United States Travis Duncan Kristine Fisher Signed (1) The employer does not elect the employers’ liability coverage. Travis Duncan projects@duncanhs.com spouse Waverly IA United States Travis Duncan Kristine Fisher Signed
451 2021-03-25 17:00 Anonymous (not verified) 166.181.80.120 Rogers conc,. const, Partnership 220804 CO, RD, ANAMOSA IA, 52205 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-25 Alex olah aolah43@gmail.com Cedar Rapids Linn Iowa Robin marie kane Augie rodreguez Signed (1) The employer does not elect the employers’ liability coverage. Kevin johnson kevinecollins@libertymutual.com Ins , Agent Appleton Dane Wisconsin Robin marie kane Augie Rodriguez Signed
1155 2022-06-14 12:44 Anonymous (not verified) 207.45.82.36 GREEN AND SHINE SERVICES INC Proprietorship 210 Ne 41st st Apt 203 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. 2022-06-14 ALEX A. LOPEZ REDONDO greenandshineservices@gmail.com ankeny polk iowa Giselle roa Marta casado Signed (1) The employer does not elect the employers’ liability coverage. Alex A Lopez Redondo greenandshineservices@gmail.com propery ankeny polk iowa Giselle Roa Marta Casado Signed
567 2021-07-08 14:22 Anonymous (not verified) 50.82.130.211 Black Cat Ice Cream, LLC Limited Liability Company 1031 Office Park Road, Suite #4, West Des Moines IA 50265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-10 Alex Carter cmins_re@mchsi.com Des Moines Polk Iowa Mary Brown Kaytee Stearns Signed (1) The employer does not elect the employers’ liability coverage. Black Cat Ice Cream, LLC cmins_re@mchsi.com Self Des Moines Polk Iowa Mary Brown Kaytee Stearns Signed
1629 2023-05-09 08:50 Anonymous (not verified) 94.188.207.223 Alex Jones Proprietorship 2423 Glass Road Northeast, Cedar Rapids, IA 52402, United State I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-09 Alex Jones ajones0425@yahoo.com Cedar Rapids Linn Iowa Jordan Nisiewicz Charles Wood Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay Missouri Jordan Loyd Charles Wood Signed
1794 2023-08-10 14:56 Anonymous (not verified) 94.188.205.169 Alex Kiler Proprietorship 10511 Main Road, La Porte City, IA 50651, United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-10 Alex Kiler alexkiler12622@gmail.com La Porte City, IA Black Hawk County Iowa Charles Woods Steve Geisler Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay Missouri Charles Wood Steven Geisler Signed
469 2021-04-12 16:49 Anonymous (not verified) 65.103.82.36 Stice Construction Proprietorship 13723 140th st W I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-07-22 Alex Stice Astice17@hotmail.com Taylor Ridge Rock Island IL Ashley Stice JIm Stice Signed (1) The employer does not elect the employers’ liability coverage. Alex Stice astice17@hotmail.com self taylor ridge rock island il Ashley stice Jim Stice Signed
296 2020-10-29 09:39 Anonymous (not verified) 174.243.81.9 Alex Vanderbeek Proprietorship 85 NE Grace Wood Drive, Waukee, Iowa 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-29 Alex Vanderbeek Vanderbeek17151@gmail.com Waukee Dallas Iowa Joe Simpson James Nelson Signed (1) The employer does not elect the employers’ liability coverage. Alex Vanderbeek Vanderbeek17151@gmail.com self WAUKEE IA United States Joe Simpson James Nelson Signed
1746 2023-07-14 09:21 Anonymous (not verified) 94.188.205.176 Alex Webb Proprietorship 4019 West Roderweis Road Cabot Ar 72023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-14 Alex Webb frankie.webb@yahoo.com Cabot Pulaski Arkansas Mark Ellis Becky Ellis Signed (1) The employer does not elect the employers’ liability coverage. Ellis Flying Service INC. fly@ellisflying.com President Newport Arkansas United States Alex Webb Becky Ellis Signed
452 2021-03-26 07:30 Anonymous (not verified) 173.31.109.49 Rogers Concrete Construction Partnership 22802 County Rd E34 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-26 Alexander Olah aolah43@gmail.com Cedar Rapids Linn Iowa Robin Marie Kane Augies Rodrigez Signed (1) The employer does not elect the employers’ liability coverage. Kevin Johnson kevinjohnson@libertymutual.com Insurance Agent Appleton Outagamie Wisconsin Robin Marie Kane Augie Rodrigez Signed
1322 2022-09-27 11:31 Anonymous (not verified) 96.31.4.134 Owens Inspection Services Limited Liability Company 598 2nd Street SE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-01 Alexander Patrick Owe s ap_owens_14@yahoo.com Hospers Sioux Iowa Michael Vander Wilt Shane Meendering Signed (1) The employer does not elect the employers’ liability coverage. Donald Patrick Owens dpowens@premieronline.net Owner Sioux Center Sioux Iowa Michael Vander Wilt Shane Meendering Signed
1454 2023-02-14 09:34 Anonymous (not verified) 94.188.207.227 Spencer Imaging Center, LLC Limited Liability Company 710 S. Grand Ave., Spencer, IA 51301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-14 Alexander Pruitt apruitt@ncn.net Spencer Clay IA Shanna Marie Kooker Chad Roemeling Signed (1) The employer does not elect the employers’ liability coverage. William Muller mullerwilliam@hotmail.com Co owner Spencer Clay IA Shanna Marie Kooker Chad Roemeling Signed
531 2021-05-26 13:02 Anonymous (not verified) 75.162.156.185 Xander Wessels Limited Liability Company 719 10TH ST 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. 2021-05-26 Alexander Wessels kprepair@outlook.com MASON CITY IA IA Dusty Howe Sadie Lonning Signed (1) The employer does not elect the employers’ liability coverage. Dusty Howe dusty.mcelectric@gmail.com Sub Contractor Mason City Cerro Gordo Iowa Dusty Howe Sadie Lonning Signed
533 2021-06-03 20:37 Anonymous (not verified) 75.162.171.128 KP Repair LLC Limited Liability Company 719 10th St. NE Mason City, 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. 2021-06-03 Alexander Wessels kprepair@outlook.com MASON CITY Cerro Gordo IA Sadie Lonning Dusty Howe Signed (1) The employer does not elect the employers’ liability coverage. Alexander Wessels kprepair@outlook.com Owner MASON CITY Cerro Gordo IA Sadie Lonning Dusty Howe Signed
2048 2024-02-16 07:42 Anonymous (not verified) 94.188.207.224 Alexandra Machedon LLC Proprietorship 319 N Western Street Stuart, IA 50250 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-16 Alexandra Machedon ali@alimachedon.com Stuart USA Iowa Jessica Cash Vicki Collins Signed (1) The employer does not elect the employers’ liability coverage. Alexandra Machedon ali@alimachedon.com Self Stuart US IA Jessi Cash Vicki Collins Signed
691 2021-10-26 14:54 Anonymous (not verified) 65.144.174.26 Alfonso Montoya Proprietorship 2114 Nw Maple 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. 2021-10-26 Alfonso Montoya fonzflooring@gmail.com Des Moines Polk Iowa Hector Montoya Victor Montoya Signed (1) The employer does not elect the employers’ liability coverage. Alfonso Montoya fonzflooring@gmail.com Owner Des Moines Polk Iowa Hector Montoya Victor Montoya Signed
1586 2023-04-19 08:38 Anonymous (not verified) 94.188.205.169 Arcos Siding, LLC Limited Liability Company 1429 22nd Street, Des Moines, IA 50311 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-19 Alfredo Arco Cruz alfredoarcos13@gmail.com Des Moines Polk Des Moines Maria Sevillana Cruz Miguel Sevillana Signed (1) The employer does not elect the employers’ liability coverage. Alfredo Arcos Cruz alfredoarco13@gmail.com Self Des Moines Polk Iowa Maria Sevillana Cruz Miguel Sevillana Signed
1470 2023-02-20 08:38 Anonymous (not verified) 94.188.205.167 Level92 Screen Printing LLC Limited Liability Company 2500 W 2nd Ave Ste 10, Indianola, IA 50125 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-20 Alison Vice orders@level92.com Indianola Warren Iowa Bill Bauer Cindy Bauer Signed (1) The employer does not elect the employers’ liability coverage. Alison Vice orders@level92.com Partner Indianola Warren Iowa Bill Bauer Cindy Bauer Signed
2071 2024-03-01 11:08 Anonymous (not verified) 94.188.207.229 Level92 Screen Printing LLC Limited Liability Company 2500 W 2nd Ave Ste 10, Indianola, IA 50125 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-01 Alison Vice orders@level92.com Indianola Warren IA Jake Vice Grant Darrah Signed (1) The employer does not elect the employers’ liability coverage. Alison Vice orders@level92.com Partner Indianola Warren IA Jake Vice Grant Darrah Signed
646 2021-09-20 08:54 Anonymous (not verified) 173.24.107.209 QCA Professional Contractors Limited Liability Company 3314 67th Ave, Moline, IL. 61265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-20 Allan Celada allancelada@qcaprocontractors.com Moline Rock Island IL Alexander Celada Drexel Miller Signed (1) The employer does not elect the employers’ liability coverage. Allan Celada allancelada@qcaprocontractors.com self Moline Rock Island IL Alexander Celada Drexel Miller Signed
1276 2022-08-19 13:43 Anonymous (not verified) 173.29.47.222 Premiere Plastering & Drywall, Inc. Proprietorship 2331 W. 63rd 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. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-08-19 Allen Aldridge allenaldridge73@yahoo.com Davenport Scott Iowa Jamie Wardlow Kandra Blumenshein Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Premiere Plastering & Drywall, Inc. premiere_pd_llc@yahoo.com Subcontractor Davenport Scott Iowa Jamie Wardlow Kandra Blumenshein Signed
1949 2023-12-11 15:20 Anonymous (not verified) 94.188.207.223 Allens construction services llc Limited Liability Company 509 Nw Scott St Ankeny, Iowa 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. 2023-12-11 Allen Cheville acsllc515@gmail.com Ankeny Polk IOWA Allen Cheville Alexis Zimmerman Signed (1) The employer does not elect the employers’ liability coverage. Allen Cheville acsllc515@gmail.com Self Ankeny Polk IOWA Allen Cheville Alexis Zimmerman Signed
1473 2023-02-20 15:57 Anonymous (not verified) 94.188.207.224 C & A Fox Farms LLC Limited Liability Company 3275 valley Ave Orchard IA 50460 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-20 Allen Fox sales@foxfarmsllc.com Orchard Mitchell Iowa Darrel Elsbernd Chris Fye Signed (1) The employer does not elect the employers’ liability coverage. Allen Fox sales@foxfarmsllc.com self Orchard Mitchell Iowa Darrel Elsbernd Chris Fye Signed
39 2020-01-19 11:00 Anonymous (not verified) 75.163.84.145 Allen L Bryen Proprietorship 2609 Madison St Bellevue NE 68005 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-19 Allen Lee Bryen Allen.Bryen@yahoo.com Bellevue Sarpy Nebraska Jeffrey Coats Donald Coats Signed (1) The employer does not elect the employers’ liability coverage. Allen L Bryen Allen.Bryen@yahoo.com Self Bellevue Sarpy Nebraska jeffrey Coats Donald Coats Signed
979 2022-03-15 13:48 Anonymous (not verified) 72.255.78.146 Custom Climates Partnership 3305 Highway 1 SW Ste 9A Iowa City IA 52240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-15 Allen Nichols ranichols4@gmail.com CEDAR RAPIDS Iowa IA Rose Nichols Rose Nichols Signed (1) The employer does not elect the employers’ liability coverage. Allen Nichols ranichols4@gmail.com spouse CEDAR RAPIDS Iowa IA Rose Nichols Rose Nichols Signed
1065 2022-04-21 16:26 Anonymous (not verified) 172.58.84.198 Royal Flooring Limited Liability Company 11801 Hickman Rd Urbandale Iowa 50323 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-21 Alondra Canedo Orta alondracanedo34@gmail.com Des Moines Polk county Iowa Alondra Canedo Marvin Bonilla Signed (1) The employer does not elect the employers’ liability coverage. Royal Flooring Workorders@shoproyalflooring.com Employee Des Moines Polk county Iowa Alondra Canedo Marvin Bonilla Signed
1068 2022-04-25 06:07 Anonymous (not verified) 172.58.84.213 Alondra Canedo Orta Limited Liability Company 4100 Hubbell Ave Apt#80 Des Moines IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-25 Alondra Canedo Orta alondracanedo34@gmail.com Des Moines Polk county Iowa Marvin Bonilla Alondra Canedo Signed (1) The employer does not elect the employers’ liability coverage. Alondra Canedo Orta alondracanedo34@gmail.com Subcontractor Installer Des Moines Polk county Iowa Marvin Bonilla Alondra Canedo Signed
1673 2023-06-02 09:30 Anonymous (not verified) 94.188.207.228 Kacena Family Tree Farm Inc Partnership 2510 55th St., Vinton, IA 52349 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-01 Alyce Lynch kacenafarms.alyce@gmail.com Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed (1) The employer does not elect the employers’ liability coverage. Alyce Lynch ashlyn@3riversins.net 25% Owner - President Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed
1257 2022-08-15 13:27 Anonymous (not verified) 173.29.47.222 Premiere Plastering & Drywall, Inc. Proprietorship 2331 W. 63rd 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. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-08-15 Amanda Carol Loeffelholz evansamanda300@yahoo.com Davenport Iowa United States Jamie Wardlow Kandra Blumenshein Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Premiere Plastering & Drywall, Inc. premiere_pd_llc@yahoo.com Subcontractor Davenport Iowa United States Jamie Wardlow Kandra Blumenshein Signed
44 2020-01-28 12:55 Anonymous (not verified) 173.24.181.211 AMANDA FIEDLER Proprietorship 10 5TH AVE NW FOSTORIA, IA 51340 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-28 AMANDA FIEDLER JOEL@WALKERINSURANCEIA.COM FOSTORIA CLAY IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The employer does not elect the employers’ liability coverage. AMANDA FIEDLER JOEL@WALKERINSURANCEIA.COM OWNER FOSTORIA CLAY IA JOSPH THOMAS LORING TAMI SUE KLEIN Signed
1421 2023-01-13 09:43 Anonymous (not verified) 96.18.190.183 Home Base Inspection & Code Services, LLC Limited Liability Company 3805 Ridge 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. 2023-01-13 Amanda Harper amanda@hbicsvs.com Sioux City IA United States Terri Harper Joy Brouilette Signed (1) The employer does not elect the employers’ liability coverage. Amanda Harper amanda@hbicsvs.com self Sioux City IA United States Terri Harper Joy Brouillette Signed
52 2020-02-04 10:35 Anonymous (not verified) 173.28.28.57 Sister Style, LLC Limited Liability Company 211 3rd Street, Parkersburg IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-23 Amanda Jorgenson cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Amanda Jorgenson cmins_re@mchsi.com Self Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed
19 2019-12-31 16:29 Anonymous (not verified) 172.58.83.45 A.M. Tile Proprietorship 3824 122nd st I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-12-31 Amar Music amarmusic01@gmail.com Urbandale IA United States Sefik Music Amara Crncevic Signed (1) The employer does not elect the employers’ liability coverage. Amar Music amarmusic01@gmail.com Owner Urbandale IA United States Sefik Music Amara Crncevic Signed
20 2019-12-31 16:36 Anonymous (not verified) 172.58.83.45 A.M. Tile Proprietorship 3824 122nd st I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-12-31 Amar Music amarmusic01@gmail.com Urbandale IA United States Sefik Music Amara Crncevic Signed (1) The employer does not elect the employers’ liability coverage. Omer Okic ultimate.exteriors@gmail.com Owner Des Moines Polk IA Sefik Music Amara Crncevic Signed
191 2020-06-23 16:09 Anonymous (not verified) 173.18.3.76 Look At You LLC Limited Liability Company 5545 Mills Civic Pkwy Ste 100 West Des Moines, IA 50265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-23 Amber Keppler keppler_ark@outlook.com Des Moines Polk IA Angela Kinsey Jon Stetzel Signed (1) The employer does not elect the employers’ liability coverage. Amber Keppler keppler_ark@outlook.com LLC Member Des Moines Polk IA Angela Kinsey Jon Stetzel Signed
688 2021-10-25 10:56 Anonymous (not verified) 75.91.173.195 Ami Westcott Proprietorship 2672 F 52 Trail Parnell, IA 52325 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-25 Ami Lynn Westcott ami.westcott@gmail.com Parmell Iowa Iowa Donald Scott Westcott Andrew Patrick Brummel Signed (1) The employer does not elect the employers’ liability coverage. Ami Lynn Westcott ami.westcott@gmail.com self Parnell Iowa Iowa Donald Scott Westcott Andrew Patrick Brummel Signed
1380 2022-11-26 07:41 Anonymous (not verified) 173.17.229.18 M&M Construction LLC Limited Liability Company 32785 Homestead 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. 2022-11-23 Amparo Yamilet Menendez Gonzalez menendez.amparo@yahoo.com Granger Dalles center United States Carla Diaz Jesus Lopez Signed (1) The employer does not elect the employers’ liability coverage. Gerardo Alvarado bariel578@gmail.com Employee Perry IA United States Carla Diaz Jesus lopez 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
63 2020-02-17 16:05 Anonymous (not verified) 173.17.12.213 ANA GARCIA GONZALEZ Limited Liability Company 4023 14TH ST DES MOINES IOWA 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-17 Ana Garcia Gonzalez gjeanettegonzalez@gmail.com DES MOINES POLK IOWA LUZ SAUCEDA SANDRA ISABEL SAUCEDA Signed (1) The employer does not elect the employers’ liability coverage. ANA GARCIA GONZALEZ GJEANETTEGONZALEZ@GMAIL.COM SELF DES MOINES POLK IA LUZ SOTELO SAUCEDO SANDRA ISABEL SAUCEDA Signed
1639 2023-05-11 07:39 Anonymous (not verified) 94.188.205.175 JYC Drywall LLC Proprietorship 1034 Grand Ave, Muscatine, IA 52761 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-11 Anastacio Zamarripa 1zama0081@gmail.com Muscatine Louisa Iowa Arcel Servin Chris Hay Signed (1) The employer does not elect the employers’ liability coverage. Anastacio Zamarripa 1zama0081@gmail.com Self Muscatine Louisa Iowa Arcel Servin Chris Hay Signed
1509 2023-03-09 10:39 Anonymous (not verified) 94.188.207.227 Andres Barboza Limited Liability Company 329 West 31 St South Sioux city ne 68776 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-09 Andres Barboza barboza79@yahoo.com South Sioux City Nebraska United States Jaime Gutierrez Gerardo ibarra Signed (1) The employer does not elect the employers’ liability coverage. Andres Barboza barboza79@yahoo.com Owner South Sioux City Nebraska United States Jaime Gutierrez Gerardo ibarra Signed
588 2021-07-27 19:59 Anonymous (not verified) 75.162.226.22 Andres Martinez Limited Liability Company 3903 SW 3rd St. Des Moines, Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-27 Andres Martinez and.am12am@gmail.com Des Moines Polk Iowa Carla Martinez Librado Martinez Signed (1) The employer does not elect the employers’ liability coverage. Andres Martinez and.am12am@gmail.com Employer Des Moines Polk Iowa Carla Martinez Librado Martinez Signed
1277 2022-08-22 08:57 Anonymous (not verified) 68.169.247.177 Andrew Betts Proprietorship 305 3rd ave sw cascade 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. 2022-08-22 Andrew Betts dbidrywallco@gmail.com Cascade Dubuque Iowa Jamie manternach Andy hall Signed (1) The employer does not elect the employers’ liability coverage. Andrew Betts dbidrywallco@gmail.com Owner Cascade Iowa United States Jamie manternach Andy hall Signed
255 2020-09-11 13:42 Anonymous (not verified) 173.190.65.6 A Fisk Trucking, LLC Limited Liability Company PO Box 332, Strawberry Point, IA 52076 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-14 Andrew Fisk afisktrucking@gmail.com Strawberry Point Clayton Iowa Pamela Vaske Crystal Thole Signed (1) The employer does not elect the employers’ liability coverage. A Fisk Trucking, LLC afisktrucking@gmail.com Member/Manager Strawberry Point Clayton Iowa Pamela Vaske Crystal Thole Signed
1084 2022-05-02 15:23 Anonymous (not verified) 173.23.196.11 Sweet Green Arborist Services, LLC Limited Liability Company 804 W. Briggs Ave, Fairfield, IA 52556 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-02 Andrew Forest Nash sweetgreenarborist@gmail.com Fairfield Jeffereson Iowa Eli Morgan Rachel Morgan Signed (1) The employer does not elect the employers’ liability coverage. Andrew Nash anash66@gmail.com same Fairfield Jeffereson Iowa Rachel Morgan Eli Morgan Signed
453 2021-03-26 08:27 Anonymous (not verified) 192.30.185.142 DYAD LLC Partnership 2308 Summit St, Sioux City, IA 51104 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-26 Andrew Glisar john@kellyconstruction.com Sioux City Woodbury IA Katie Jenks Jenni Ebner Signed (1) The employer does not elect the employers’ liability coverage. Andrew Glisar john@kellyconstruction.com Owner/Partner Sioux City Woodbury IA Katie Jenks Jenni Ebner Signed
456 2021-04-02 10:02 Anonymous (not verified) 207.177.7.191 Goettsch Dispatch Inc Limited Liability Company 200 Main St Galva, IA 51020 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-15 Andrew Goettsch andygoettsch@gmail.com Galva Ida Iowa Kristy Dewey Terri Ullrich Signed (1) The employer does not elect the employers’ liability coverage. Andrew Goettsch andygoettsch@gmail.com President Galva Ida Iowa Kristy Dewey Terri Ullrich Signed
1813 2023-08-22 15:44 Anonymous (not verified) 94.188.205.176 Hart and Company Limited Liability Company PO Box 757 Indianola 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. 2023-08-22 Andrew Hart hartinnovate@gmail.com Ackworth Warren Iowa John M Keller Logan David Signed (1) The employer does not elect the employers’ liability coverage. Andrew Hart hartinnovate@gmail.com Self Ackworth Warren Iowa John M Keller Logan David Signed
1852 2023-09-24 16:02 Anonymous (not verified) 94.188.205.174 Handy Andy Enterprises LLC Limited Liability Company PO Box 479, Williamsburg, Iowa 52361 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-01 Andrew J Garner andy@handyandyenterprises.net Williamsburg Iowa Iowa Amanda Bowen Kent Pope Signed (1) The employer does not elect the employers’ liability coverage. Andrew J Garner agarner6977@gmail.com Owner Williamsburg Iowa Iowa Amanda Bowen Kent Pope Signed
1651 2023-05-16 22:18 Anonymous (not verified) 94.188.205.175 Corridor Cleaning Services, LLC Limited Liability Company 4621 Orchard Dr NW, Cedar Rapids, Iowa, 52405 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-11 Andrew Kleineck andrew@corridorcleaning.net Cedar Rapids Linn Iowa Cole Smith Suzanne Brue Signed (1) The employer does not elect the employers’ liability coverage. Andrew Kleineck andrew@corridorcleaning.net LLC Member Cedar Rapids Linn Iowa Cole Smith Suzanne Brue Signed
1733 2023-07-10 14:30 Anonymous (not verified) 94.188.205.177 Leaf home Proprietorship 1595 Georgetown Rd., Hudson, OH 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. 2023-07-10 Andrew Koske aokoz_23@outlook.com East Moline IL United States Andrew Koske Andrew Koske Signed (1) The employer does not elect the employers’ liability coverage. Andrew Koske aokoz_23@outlook.com None East Moline IL United States Andrew Koske Andrew Koske Signed
2154 2024-04-16 08:05 Anonymous (not verified) 94.188.207.226 Lanz Pork Inc Proprietorship 12905 N 1050th Road, Macomb, IL 61455 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-02 Andrew M Riggins kellylanz1967@gmail.com Macomb IL United States Barb Coker Scott Caspall Signed (1) The employer does not elect the employers’ liability coverage. Andrew M Riggins kellylanz1967@gmail.com Self Macomb IL United States Barb Coker Scott Caspall Signed
2155 2024-04-16 08:13 Anonymous (not verified) 94.188.207.225 Andrew M Riggins Proprietorship 12905 N 1050th Road, Macomb, IL 61455 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-02 Andrew M Riggins kellylanz1967@gmail.com Macomb IL United States Barb Coker Scott Caspall Signed (1) The employer does not elect the employers’ liability coverage. Andrew M Riggins kellylanz1967@gmail.com Self Macomb IL United States Barb Coker Scott Caspall Signed
1461 2023-02-17 07:48 Anonymous (not verified) 94.188.205.168 Great Blinds LLC Limited Liability Company 5174 Parkridge 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. 2023-02-17 Andrew Mohrfeld mohrfeldandy@yahoo.com Pleasant Hill Polk IA Andrew Mohrfeld Martin Mohrfeld Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. John Lovell Jon@jlovellco.com None Urbandale Polk IA Andrew Mohrfeld Martin Mohrfeld Signed
2166 2024-04-20 13:38 Anonymous (not verified) 94.188.205.175 Cedar Valley Seamless, LLC Limited Liability Company 1184 215th St, Jesup, IA 50648 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-20 Andrew Richard Trumbauer cedarvalleyseamlessllc@gmail.com Jesup Buchanan Iowa James William Masteller Andrew William Hamilton Signed (1) The employer does not elect the employers’ liability coverage. Andrew Richard Trumbauer cedarvalleyseamlessllc@gmail.com Owner/Operator Jesup Buchanan Iowa James William Masteller Andrew William Hamilton Signed
557 2021-07-07 09:51 Anonymous (not verified) 66.188.136.150 Andrew Thompson-Sutherland Proprietorship 3200 Daniel Lane Apt. 207 Monroeville, PA 15146 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-06 Andrew Thompson-Sutherland kschumacher@tricorinsurance.com Monroeville Allegheny PA Mitch Kemp Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Andrew Thompson-Sutherland kschumacher@tricorinsurance.com Same Monroeville Allegheny PA Mitch Kemp Shuree Behr Signed
864 2022-01-27 12:50 Anonymous (not verified) 67.55.155.207 Chamra Farms Limited Liability Company 3031 215 th 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. 2022-01-01 Andy Chamra apchamra@gmail.com Rose Hill Iowa United States Steve Weller Connie VanKlootwyk Signed (1) The employer does not elect the employers’ liability coverage. Steven Weller steve.weller@insurancestationinc.com Agent OSKALOOSA Iowa United States Andy Chamra Connie Van Klootwyk Signed
1844 2023-09-14 14:15 Anonymous (not verified) 94.188.205.177 Royal Gutters & Construction, LLC Limited Liability Company 1420 120th Street, Hazleton, IA 50641 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-01 Andy Hershberger hershbergera@gmail.com Hazleton Buchanan Iowa Eli Raber Steve Frost Signed (1) The employer does not elect the employers’ liability coverage. Andy Herschberger hershbergera@gmail.com self Hazleton Buchanan Iowa Eli Miller Steve Frost Signed
1237 2022-08-01 22:40 Anonymous (not verified) 50.80.97.239 Andy Fiala Proprietorship 1628 34th St. 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. 2022-08-01 Andy W Fiala fialaandy1@gmail.com Cedar Rapids IA United States John A Hasson Scott M Fiala Signed (1) The employer does not elect the employers’ liability coverage. Andy W Fiala fialaandy1@gmail.com Owner Cedar Rapids IA United States John A Hasson Scott M Fiala Signed
267 2020-09-22 07:04 Anonymous (not verified) 74.84.65.174 Angel Jesus Argueta Proprietorship 1523 Arlington Ave Des Moines, IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-22 Angel Jesus Argueta Juanargueta22@yahoo.com Des Moines Polk Iowa Larry Eugene Guire Eric Michael West Signed (1) The employer does not elect the employers’ liability coverage. Angel Jesus Argueta Juanargueta22@yahoo.com Same Des Moines Polk Iowa Larry Eugene Guire Eric Michael West Signed
76 2020-02-24 15:05 Anonymous (not verified) 97.64.133.18 Sky Roofing Partnership 1332 Idaho St., Des Moines, IA 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-01 Angel Jurado Liberty21424@gmail.com des moines Polk Iowa Valerie Cramer David Murray Signed (1) The employer does not elect the employers’ liability coverage. Cramer Law PLC cramerlaw@halousa.com Attorney Polk Polk Iowa Sara Mc Ginnis David Murray Signed
160 2020-05-18 15:04 Anonymous (not verified) 173.28.28.57 Angela Scanlan Proprietorship 26436 320th Street, Parkersburg IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-28 Angela Scanlan cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Angela Scanlan cmins_re@mchsi.com Self Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed
625 2021-08-30 20:39 Anonymous (not verified) 173.16.140.101 Phthalo Consulting LLC Limited Liability Company 2917 47th St, Des Moines, IA 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-30 Angela Stone-Wiegert angela@phthaloconsulting.com Des Moines Polk Iowa Sonya Shippy Kenny Shippy Signed (1) The employer does not elect the employers’ liability coverage. Angela Stone-Wiegert angela@phthaloconsulting.com Owner Des Moines Polk Iowa Sonya Shippy Kenny Shippy Signed
27 2020-01-06 09:17 Anonymous (not verified) 24.149.10.119 Miss Wonderful LLC Limited Liability Company 216 Main St Cedar Falls, IA 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-06 Ann Eastman misswonderful216@gmail.com Cedar Falls Black Hawk IA Rachel Lee Ann Remmert Signed (1) The employer does not elect the employers’ liability coverage. Ann Eastman misswonderful216@gmail.com Owner Cedar Falls Black Hawk IA Rachel Lee Ann Remmert Signed
1483 2023-02-25 14:57 Anonymous (not verified) 94.188.205.168 Van Wyk Lawn Services Limited Liability Company 14486 S. 128th ave E. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-24 Anthony Eugene Van Wyk vanwykturf@gmail.com Lynnville Iowa United States Ashley Lynn Van Wyk Abby Christine Peterson Signed (1) The employer does not elect the employers’ liability coverage. Anthony Eugene Van Wyk vanwykturf@gmail.com Self/Owner Lynnville Iowa United States Ashley Lynn Van Wyk Abby Christine Peterson Signed
2093 2024-03-13 15:53 Anonymous (not verified) 94.188.205.176 Tony Deutmeyer Limited Liability Company PO BOX 152 HIAWATHA IA 52233 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-13 Anthony John Deutmeyer tonydeutmeyer@gmail.com Hiawatha Linn Iowa Lacey riley Andrew prochaska Signed (1) The employer does not elect the employers’ liability coverage. Anthony Deutmeyer tonydeutmeyer@gmail.com Self Hiawatha Linn Iowa Lacey riley Andrew prochaska Signed
234 2020-08-18 09:13 Anonymous (not verified) 67.55.224.208 Anthony Keahi dba Hawaiian Handyman Proprietorship 928 8th Ave SE, Sioux Center, IA 51250-2502 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-17 Anthony Keahi hhkeahi@gmail.com Sioux Center Sioux Iowa Kyle Blankers Julia Huisman Signed (1) The employer does not elect the employers’ liability coverage. Anthony Keahi hhkeahi@gmail.com Self - sole proprietorship Sioux Center Sioux Iowa Kyle Blankers Julia Huisman Signed
1048 2022-04-14 14:17 Anonymous (not verified) 208.38.229.255 Mean Green Lawn Care Limited Liability Company 2628 W 59th st Davenport Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-14 Anthony mccash meangreenlawncare20@gmail.com Davenport Scott Iowa Clarissa Oliva Julie Thornman Signed (1) The employer does not elect the employers’ liability coverage. Anthony McCash meangreenlawncare20@gmail.com Owner Davenport Scott Iowa Clarissa Oliva Julie Thornman Signed
1833 2023-09-08 13:39 Anonymous (not verified) 94.188.207.225 Superior painting & epoxy coatings llc Limited Liability Company 4918 ne crestmoor ln I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-05 Anthony Negrete jr superior.paint@hotmail.com Ankeny IA United States Stacey Marie stoecker Anthony Negrete jr. Signed (1) The employer does not elect the employers’ liability coverage. Anthony Negrete jr superior.paint@hotmail.com Spouse Ankeny IA United States Anthony Negrete jr stacey marie Stoecker Signed
2191 2024-04-29 10:09 Anonymous (not verified) 94.188.207.225 Anthony Rakestraw Proprietorship 1262 S Kellogg St., Galesburg, IL 61401 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-29 Anthony Rakestraw gazzork2@yahoo.com Galesburg Know Illinois Cheryl Ross Larry Rheinschmidt Signed (1) The employer does not elect the employers’ liability coverage. Anthony Rakestraw gazzork2@yahoo.com owner Galesburg Knox Illinois Cheryl Ross Larry Rheinschmidt Signed
1205 2022-07-14 13:29 Anonymous (not verified) 173.18.22.217 Residence Electric LLC Limited Liability Company 5465 Mills Civic Pkwy #317 West Des Moines 50266 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-14 Anthony Rivera residenceelectric@outlook.com West Des Moines Polk Iowa Lesa Reeves Erick Schuldt Signed (1) The employer does not elect the employers’ liability coverage. Anthony Rivera residenceelectric@outlook.com Owner West Des Moines Polk Iowa Lesa Reeves Erick Schuldt Signed
1693 2023-06-16 11:37 Anonymous (not verified) 94.188.207.230 Anthony Scroggins Proprietorship 301 SE 11th Street , Unit 807 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-16 Anthony Scroggins scroggins710@gmail.com Grimes Polk IA Cody Wavada Nate Duden Signed (1) The employer does not elect the employers’ liability coverage. Anthony Scroggins scroggins710@gmail.com Self Grimes Polk IA Cody Wavada Nate Duden Signed
2074 2024-03-04 16:56 Anonymous (not verified) 94.188.207.224 IG painting Llc Limited Liability Company 416 51st ST West 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. 2024-03-01 antonio J Iglesias antonio_joserene@hotmail.com west Des moines polk iowa Raul Gomez Bruno Cruz Signed (1) The employer does not elect the employers’ liability coverage. Antonio J Iglesias antonio_joserene@hotmail.com not relationship West des Moines polk iowa Raul Gomez Bruno cruz Signed
771 2021-11-22 20:29 Anonymous (not verified) 75.162.65.250 Art Flooring LLC Limited Liability Company 1225 Emma Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-23 Antonio Rojas artfloorsllc@gmail.com 1225 Emma Ave Polk Iowa Antonio Rojas Hilda Rojas Signed (1) The employer does not elect the employers’ liability coverage. Antonio Rojas artfloorsllc@gmail.com self same as above same as above iowa Antonio Rojas Hilda Rojas Signed
1154 2022-06-14 00:27 Anonymous (not verified) 174.213.144.227 Arben Bahtirovic Partnership 3060 South East Grimes Blvd, Suite 100-300 Grimes, Iowa 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. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-06-14 Arben Bahtirovic arben2002@gmail.com West Des Moines Polk IOWA Senida bahtirovic Mario mandic Signed (1) The employer does not elect the employers’ liability coverage. Arben Bahtirovic arben2002@gmail.com Contractor West Des Moines Polk IOWA Senida bahtirovic Marijo mandic Signed
1628 2023-05-09 08:00 Anonymous (not verified) 94.188.205.175 Servin Drywall Proprietorship 6311 Underwood Ave SW, Cedar Rapids, IA 52404 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-09 Arcel Servin arcelservin77@gmail.com Cedar Rapids Linn Iowa Rolandas Bitanas Kirk Strunk Signed (1) The employer does not elect the employers’ liability coverage. Arcel Servin arcelservin77@gmail.com Self Cedar Rapids Linn Iowa Rolandas Bitanas Kirk Strunk Signed
1385 2022-12-08 18:45 Anonymous (not verified) 173.26.84.6 Fansco LLC Limited Liability Company 620 2 nd Ave SE Cresco IOWA 52136 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-12-08 Arif Sheikh Sheikha44@yahoo.com Cresco Howard IOWA Bibi Sheikh Usman Sheikh Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Arif Sheikh Sheikha44@yahoo.com Relative Henderson Clark Navada Bibi Sheikh Usman Sheikh Signed
1386 2022-12-09 08:35 Anonymous (not verified) 173.26.84.6 Fansco LLc DBA Cresco motel Limited Liability Company 620 2 nd Ave SE Cresco IOwa 52136 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-09 Arif Sheikh Sheikha44@yahoo.com Cresco Howard IOWA Bibi Sheikh Usman Sheikh Signed (1) The employer does not elect the employers’ liability coverage. Arif Sheikh Sheikha44@yahoo.com Self CRESCO Howard IOWA Bibi Sheikh Usman Sheikh Signed
2008 2024-01-29 14:45 Anonymous (not verified) 94.188.207.230 DB2P Limited Liability Company 5904 Ashworth 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. 2024-01-29 Arjun Dahal allcoolliquors@gmail.com West Des Moines Dallas Iowa Jayson Jones Nikki Wilks Signed (1) The employer does not elect the employers’ liability coverage. Jayson Jones jayson@jonesinsured.com Insurance Agent Urbandale Dallas Iowa Jayson Jones Nikki Wilks Signed
1026 2022-04-01 14:53 Anonymous (not verified) 173.31.148.43 ARMANDO RESENDEZ Proprietorship 202 S 13TH ST APT #8 ESTHERVILLE, IA 51334 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 ARMANDO RESENDEZ joel@walkerinsuranceia.com Estherville EMMET IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The employer does not elect the employers’ liability coverage. ARMANDO RESENDEZ joel@walkerinsuranceia.com SELF Estherville EMMET IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
704 2021-11-01 18:43 Anonymous (not verified) 157.52.56.205 Martin Clip & Trim LLC Limited Liability Company 204 Oak Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-30 Armin Harold Martin arminbonnie@aol.com Urbana Benton Iowa Melissa Linn Stieferman Bronna Mae Gubbels Signed (1) The employer does not elect the employers’ liability coverage. Armin Harold Martin arminbonnie@aol.com self Urbana Benton Iowa Melissa Linn Stieferman Bronna Mae Gubbels Signed
1362 2022-11-08 08:36 Anonymous (not verified) 157.52.56.205 Martin Clip & Trim LLC Proprietorship Box 383 Urbana Iowa 52345 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-08 Armin Martin arminbonnie@aol.com Urbana Benton Iowa Melissa Stieferman Christin Martin Signed (1) The employer does not elect the employers’ liability coverage. Armin Martin arminbonnie@aol.com Self Urbana Benton Iowa Melissa Stieferman Christin Martin Signed
584 2021-07-23 15:38 Anonymous (not verified) 75.162.41.54 Bradens Roofing & Construction LLc Limited Liability Company 2450 Hart Ave, Des Moines, IA 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-23 Arsenio Vargas avargas409@gmail.com Des Moines Polk Iowa Marc Black Jason Anderson Signed (1) The employer does not elect the employers’ liability coverage. Arsenio Vargas avargas409@gmail.com Owner Des Moines Polk Iowa Marc Black Jason Anderson Signed
672 2021-10-13 16:05 Anonymous (not verified) 75.162.218.218 Arturos Interiors LLC Limited Liability Company 3305 se 22nd apt 15 Des Moines IA 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-29 Arturo mejia arturomcruz20@hotmail.com Des Moines polk IA yolanda mendoza liliana sanchez Signed (1) The employer does not elect the employers’ liability coverage. Arturo Mejia arturomcruz20@hotmail.com member Des Moines polk IA Yolanda Mendoza lialiana sanchez Signed
1711 2023-06-26 16:50 Anonymous (not verified) 94.188.207.224 Innovative Behavioral Therapy, LLC Limited Liability Company 915 Main St. Adel IA 50003 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-26 Ashley Andrew ashley@innovativebehavioraltherapy.com Adel Dallas Iowa Thomas Atherton Brenda Barto Signed (1) The employer does not elect the employers’ liability coverage. Ashley Andrew ashley@innovativebehavioraltherapy.com Self Adel Dallas Iowa Thomas Atherton Brenda Barto Signed
1894 2023-11-03 10:02 Anonymous (not verified) 94.188.205.167 ASHLEY QUAIL DBA: RUSTIC ROOTS SALON Proprietorship 33596 SCHANY DR, RUTHVEN, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-03 ASHLEY QUAIL ashley-mazzanti@hotmail.com RUTHVEN PALO ALTO IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. ASHLEY QUAIL ashley-mazzanti@hotmail.com SELF RUTHVEN PALO ALTO IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1376 2022-11-18 10:22 Anonymous (not verified) 166.181.87.119 Ashley Heffernen Proprietorship 4009 Majestic Ct NE Cedar Rapids Iowa 52411 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-18 Ashley Rae Heffernen ashley.heffernen@gmail.com Cedar Rapids Linn Iowa Kyle Reid Amanda Frese Signed (1) The employer does not elect the employers’ liability coverage. Ashley Rae Heffernen ashley.heffernen@gmail.com Self Cedar Rapids Linn Iowa Kyle Reid Amanda Frese Signed
2164 2024-04-19 13:52 Anonymous (not verified) 94.188.205.167 RKB Designs LLC Limited Liability Company 4333 Cedar 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. 2024-04-19 Ashley Rocca roccafive@gmail.com Davenport IA United States Nicholas Rocca Joni Long Signed (1) The employer does not elect the employers’ liability coverage. Ashley Rocca roccafive@gmail.com Self Davenport IA United States Nicholas Rocca Joni Long Signed
1738 2023-07-11 10:51 Anonymous (not verified) 94.188.207.224 Augustin Santos Proprietorship 109 Loomis Ave Des Moines, Iowa 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-05 Augustin Santos deb@piciowa.com Des Moines Polk Iowa Deb Stratton Kelly Denger Signed (1) The employer does not elect the employers’ liability coverage. Augustin Santos deb@piciowa.com self Des Moines Polk Iowa Deb Stratton Kelly Denger Signed
128 2020-04-24 14:14 Anonymous (not verified) 173.21.123.73 JLC Finish Trim Carpenter inc Proprietorship 2620 61st st des moines iowa 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-24 aura cordova mendoza isabel_menro81@yahoo.com des moines polk iowa emily segura roslyn duenas Signed (1) The employer does not elect the employers’ liability coverage. Jose Mendoza jlctrimcarpenterinc@gmail.com employer des moines polk iowa emily segura roslyn duenas Signed
2016 2024-02-01 09:20 Anonymous (not verified) 94.188.207.225 Imperium Outdoor Solutions Proprietorship 114 W Clanton St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-01 Austin Beener abeener033@gmail.com St Charles IA United States Austin Beener Austin Beener Signed (1) The employer does not elect the employers’ liability coverage. Austin Beener abeener033@gmail.com Operator St Charles IA United States Austin Beener Austin Beener Signed
1188 2022-07-07 11:24 Anonymous (not verified) 107.117.176.70 Pitts Aerial Services LLC Limited Liability Company 2478 county road 1488 Cullman al 35058 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-07 Austin Branch Pitts pittsaerial@gmail.com Cullman Cullman AL Sydney Pitts James Robertson Signed (1) The employer does not elect the employers’ liability coverage. Austin Branch Pitts pittsaerial@gmail.com Owner Cullman Cullman AL Sydney Pitts James Robertson Signed
1189 2022-07-07 11:50 Anonymous (not verified) 71.91.55.59 Austin Branch Pitts Proprietorship 2478 county road 1488 Cullman al 35058 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-07 Austin Branch Pitts pittsaerial@gmail.com Cullman Cullman AL Sydney Pitts James Robertson Signed (1) The employer does not elect the employers’ liability coverage. Austin Branch Pitts pittsaerial@gmail.com Proprietor Cullman Cullman AL Sydney Pitts James Robertson Signed
750 2021-11-16 12:34 Anonymous (not verified) 172.58.83.130 Austin Carlson Proprietorship 1341 iron city avenue atalissa 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. 2021-11-16 Austin Carlson toppeakconstruction@gmail.com Atalissa Muscating Iowa Jordan Nisiewicz Sam Apponey Signed (1) The employer does not elect the employers’ liability coverage. Jorden Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Jackson Missouri Jordan Nisiewicz Sam Apponey Signed
1324 2022-09-30 10:19 Anonymous (not verified) 172.86.18.249 Red Beard Buildings Limited Liability Company 511 16th St. Belle Plaine, IA 52208 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-30 Austin Carnes austin_carnes@hotmail.com Belle Plaine Benton IA Craig Roster Connor Doran Signed (1) The employer does not elect the employers’ liability coverage. Austin Carnes austin_carnes@hotmail.com President Belle Plaine Benton IA Craig Roster Connor Doran Signed
1207 2022-07-15 10:02 Anonymous (not verified) 75.89.78.50 A&J Remodeling LLC Limited Liability Company 2 Bungalow Ct Newton, Iowa 50208 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-15 Austin Hudson ahudson7536@gmail.com Newton Jasper IA Liz Allen Dustin Ingram Signed (1) The employer does not elect the employers’ liability coverage. Austin Hudson anjremodel@gmail.com Co-owner Newton Jasper IA Liz Allen Dustin Ingram Signed
558 2021-07-07 13:35 Anonymous (not verified) 66.188.136.150 Austin Kalfus Sr. Proprietorship 1203 Poppy Ave. Pensacola, FL 32507 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-07 Austin Kalfus Sr. kschumacher@tricorinsurance.com Pensacola Escambia FL Mitch Kemp Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Austin Kalfus Sr. kschumacher@tricorinsurance.com Same Pensacola Escambia FL Mitch Kemp Shuree Behr Signed
1820 2023-08-28 08:12 Anonymous (not verified) 94.188.205.177 LLAD Services LLC Limited Liability Company 1611 Esplanade Avenue 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. 2023-08-28 Austin Lee Terry austinfarrell92@gmail.com Davenport Scott Iowa Cody Dunbar Jordan Loyd Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz JNisiewicz@leafhome.com Recruiter Kansas City Clay Missouri Cody Dunbar Jordan Loyd Signed
933 2022-02-23 10:57 Anonymous (not verified) 104.37.139.87 Jacobsen Transfer Limited Liability Company 1773 20th 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. 2022-02-23 Austin Moffat austinmoffatt@gmail.com tabor von homme south dakota austin moffatt jesse jacobsen Signed (1) The employer does not elect the employers’ liability coverage. Jesse Jacobsen jacobsentransfer@gmail.com employee bancorft cuming Nebraska Jesse Jacobsen Austin moffatt Signed
1952 2023-12-12 13:26 Anonymous (not verified) 94.188.205.167 Austin Albin Proprietorship 2263 Railroad Street, Jacksonville, IL 62650 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-23 Austin R Albin albinaustin12@gmail.com Jacksonville Morgan IL Wayne Albin Jerry Roth Signed (1) The employer does not elect the employers’ liability coverage. Austin R Albin albinaustin12@gmail.com Self Jacksonville Morgan IL Wayne Albin Jerry Roth Signed
1416 2023-01-09 13:05 Anonymous (not verified) 67.55.184.55 Austin Lanz Proprietorship 3015 M 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. 2023-01-09 Austin Robert Lanz austinlanz52@gmail.com Moring Sun Iowa IA Robert Lowell Lanz Jessica Leann Ewart Signed (1) The employer does not elect the employers’ liability coverage. Austin Robert Lanz austinlanz52@gmail.com Self Moring Sun Iowa IA Robert Lowell Lanz Jessica Leann Lanz Signed
1578 2023-04-17 15:33 Anonymous (not verified) 94.188.205.174 Spark Train Express LLC Limited Liability Company 16877 500th St, Pocahontas, IA 50574 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-17 Austin Sparks sparksaustin.11@gmail.com Pocahontas Pocahontas Iowa Stephanie Webbink Christian Lynch Signed (1) The employer does not elect the employers’ liability coverage. Austin Sparks sparksaustin.11@gmail.com Owner Pocahontas Pocahontas Iowa Stephanie Webbink Christian Lynch Signed
2110 2024-03-21 13:29 Anonymous (not verified) 94.188.205.174 Baroga Stone Masonry LLC Proprietorship 1228 Loomis Ave Des Moines, IA 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-21 Bacilio Rodriguez barogastonemasonry@gmail.com Des Moines Polk Iowa Drakkar Rapaich Fabi Palomares Signed (1) The employer does not elect the employers’ liability coverage. Bacilio Rodriguez barogastonemasonry@gmail.com Self Des Moines Polk Iowa Drakkar Rapaich Fabi Palomares Signed
737 2021-11-11 14:33 Anonymous (not verified) 72.13.16.172 BADGER COUNTRY TRUCKING LLC Limited Liability Company 3877 US HWY 35 AND 61 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-13 BADGER COUNTRY TRUCKING LLC dave@allseasonstrucking.com POTOSI GRANT WI Dave Neuwohner BEN MOYER Signed (1) The employer does not elect the employers’ liability coverage. BADGER COUNTRY TRUCKING LLC dave@allseasonstrucking.com PRESIDENT POTOSI GRANT WI Dave Neuwohner BEN MOYER Signed
1384 2022-12-08 13:11 Anonymous (not verified) 172.58.81.43 Sehic G&S, LLC. Limited Liability Company 4201 62nd st apt 4 Urbandale Ia 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-09 Bajro sehic kalesija20@gmail.com Urbandale Polk Iowa N/A N/A Signed (1) The employer does not elect the employers’ liability coverage. Bajro sehic kalesija20@gmail.com Owner Urbandale Polk Iowa N/A N/A Signed
1395 2022-12-15 08:02 Anonymous (not verified) 172.58.84.122 Sehic G&S, LCC Limited Liability Company 4201 62nd st Urbandale iowa 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-15 Bajro sehic kalesija20@gmail.com Urbandale Polk Iowa Bajro Bajro Signed (1) The employer does not elect the employers’ liability coverage. Bajro sehic kalesija20@gmail.com Owner Urbandale Dallas Iowa Bajro Bajro Signed
41 2020-01-20 14:26 Anonymous (not verified) 173.24.181.211 BARBARA HOOGEVEEN Proprietorship 304 MILL POND RD, ROCK RAPIDS, IA 51246 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-20 BARBARA HOOGEVEEN MCGILLH@MTCNET.NET ROCK RAPIDS LYON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The employer does not elect the employers’ liability coverage. BARABARA HOOGEVEEN MCGILLH@MTCNET.NET OWNER ROCK RAPIDS LYON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
782 2021-12-08 10:11 Anonymous (not verified) 173.21.158.248 Barry Duncan Proprietorship 2020 S.E. Four Seasons 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. 2021-12-08 BARRY DUNCAN bduncan1452@gmail.com Ankeny IA Iowa Kathy Belieu Summer Belieu-Slemp Signed (1) The employer does not elect the employers’ liability coverage. BARRY DUNCAN bduncan1452@gmail.com Self Ankeny Polk Iowa Kathy Belieu Summer Belieu-Slemp Signed
1341 2022-10-23 14:31 Anonymous (not verified) 97.127.255.147 Traver Home Improvement Limited Liability Company 14150 110 th Ave. Davenport, IA 52804 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-24 Barry S Traver traverhomeimprovement@gmail.com Davenport IA United States Denise Baughman Joni Bryant Signed (1) The employer does not elect the employers’ liability coverage. Barry S Traver traverhomeimprovement@gmail.com self Davenport IA United States Denise Baughman Joni Bryant Signed
106 2020-03-31 10:42 Anonymous (not verified) 209.152.77.101 Bart Fuller & James Fuller DBA Fuller & Sons Partnership 1302 Lincoln ST., Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-31 Bart Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Janice Henningsen Louise Helmke Signed (1) The employer does not elect the employers’ liability coverage. Bart Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Janice Henningsen Louise Helmke Signed
461 2021-04-06 08:49 Anonymous (not verified) 209.152.77.101 Bart Fuller & James Fuller DBA Fuller & Sons Partnership 1302 Lincoln ST., Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-06 Bart Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. Bart Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed
975 2022-03-15 10:34 Anonymous (not verified) 209.152.77.101 Bart Fuller & James Fuller DBA Fuller & Sons Partnership 1302 Lincoln ST., Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-15 Bart Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. Bart Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed
1516 2023-03-14 09:00 Anonymous (not verified) 94.188.207.225 Bart Fuller & James Fuller DBA Fuller & Sons Partnership 1302 Lincoln ST., Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-14 Bart Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. Bart Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed
2140 2024-04-09 09:28 Anonymous (not verified) 94.188.205.175 Bart Fuller& James Fuller DBA Fuller & Sons Partnership 1302 Lincoln Street Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-09 Bart Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Kathryn Kelley Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. Bart Fuller goffins@ruthventel.com Partner Ruthven PAlo Alto Iowa Kathryn Kelley Janice Henningsen Signed
697 2021-10-28 15:30 Anonymous (not verified) 208.126.114.236 bartman express Limited Liability Company 1976 240th st bennett iowa 52721 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 bartin joesph steines bartmanexpress@gmail.com bennett cedar iowa Robert theordore jarrett dana marie shipler Signed (1) The employer does not elect the employers’ liability coverage. bartin joesph steines bartmanexpress@gmail.com self bennett cedar iowa robert theordore jarrett dana marie shipler Signed
1905 2023-11-13 21:35 Anonymous (not verified) 94.188.205.167 Bartolo Lopez Limited Liability Company 2404 cass st Fort Worth tx 76112 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-13 Bartolo Lopez bartololopez3737@gmail.com Fort Worth tx Tarrant county Tx Airan Zamudio Carlos Lopez Signed (1) The employer does not elect the employers’ liability coverage. Bartolo Lopez bartololopez3737@mail.com Boss of the company Fort Worth Tarrant county Texas Airan Zamudio Carlos lopez Signed
599 2021-08-09 22:57 Anonymous (not verified) 70.39.22.76 The Bartman Express LLC Limited Liability Company 1976 240th St. Bennett IA 52721 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-09 Barton Steines bartmanexpress@gmail.com Bennett Cedar Iowa Robert Jarrett Michael Sexton Signed (1) The employer does not elect the employers’ liability coverage. Barton Steines bartmanexpress@gmail.com Self Bennett Cedar Iowa Robert Jarrett Michael Sexton Signed
1990 2024-01-16 22:22 Anonymous (not verified) 94.188.205.168 DeltaPro Painting & Remodeling Limited Liability Company 1115 Nolan Court North Liberty 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. 2024-01-16 Bayron Amador bayronamador59@gmail.com North Liberty IA Estados Unidos Claudia Garmendia Marlon Amador Signed (1) The employer does not elect the employers’ liability coverage. Bayron Amador bayronamador59@gmail.com Owner/Employer North Liberty IA Estados Unidos Claudia Garmendia Marlon Amador Signed
1970 2023-12-29 10:01 Anonymous (not verified) 94.188.205.168 Beatrice Banura Proprietorship 14511 Bentwood Dr, Urbandale IA 50323 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-29 Beatrice Banura banurabeatrice4@gmail.com Urbandale Dallas IA Priscilla Saina Gideon Saina Signed (1) The employer does not elect the employers’ liability coverage. Beatrice Banura banurabeatrice4@gmail.com Self employed Urbandale IA IA Priscilla Saina Gideon Saina Signed
1969 2023-12-28 15:46 Anonymous (not verified) 94.188.205.176 Beau Vander Sluis Proprietorship 3000 Seneca Avenue I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-28 Beau Vander Sluis beauvsluis@gmail.com Des Moines Polk United States Braden Banning Andrew Behanish Signed (1) The employer does not elect the employers’ liability coverage. Beau Vander Sluis beauvsluis@gmail.com Same Des Moines Polk United States Braden Banning Andrew Behanish Signed
1387 2022-12-10 22:39 Anonymous (not verified) 98.156.163.144 Springfield Staffing Solution Limited Liability Company 14918 Tuff Rd, Manor TX 78653 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-10 Beluchukwu Ebede admin@springfield-staffing.com Manor Travis United States Oluchukwu Nwokoye Beluchukwu Ebede Signed (1) The employer does not elect the employers’ liability coverage. Beluchukwu Ebede admin@springfield-staffing.com Self Manor Travis United States Oluchukwu Nwokoye Beluchukwu Ebede Signed
1626 2023-05-05 11:16 Anonymous (not verified) 94.188.205.166 I HAWK BUILDERS LLC Limited Liability Company 1417 INDIAN HILLS DR SPIRIT LAKE, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-05 BEN BRANT babrant99@yahoo.com SPIRIT LAKE DICKINSON IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. BEN BRANT joel@walkerinsuranceia.com SELF SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
569 2021-07-09 12:18 Anonymous (not verified) 173.17.250.209 Forest Ave Outreach dba Good Vibes Movement Limited Liability Company 1600 6th Ave DSM IA 50314 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-09 Ben Spellman ben@goodvibesmovement.org Des Moines IA United States Joel Donaghy Brian Donaghy Signed (1) The employer does not elect the employers’ liability coverage. Maya Bromolson maya@goodvibesmovement.org Executive Director Des Moines IA United States Joel Donaghy Brian Donaghy Signed
1292 2022-09-02 13:26 Anonymous (not verified) 173.20.146.6 Nicci Keck LLC Limited Liability Company 1107 Pheasant Valley St, Iowa City, IA 52246 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-02 Benjamin Darbro darbrob@gmail.com Iowa City Iowa United States Evangeline Kadera Denise Kandel Signed (1) The employer does not elect the employers’ liability coverage. Nicole Keck niccikeckllc@gmail.com Managing Member/Owner/President Iowa City Johnson Iowa Evangeline Kadera Denise Kandel Signed
1545 2023-03-29 20:15 Anonymous (not verified) 94.188.205.176 Leaf Filter LLC Limited Liability Company 1595 georgetown road 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. 2023-03-29 Benjamin Joseph Truitt Bjt1228@yahoo.com Springville Linn Iowa Benjamin Joseph Truitt Jordan Nisiewiczi Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewiczi jnisiewicz@leafhome.com Regional field recruiter 2 Riverside Gallatin Montana Benjamin Joseph Truitt Jordan Nisiewiczi Signed
198 2020-07-08 17:35 Anonymous (not verified) 162.218.47.214 Olsem Aerial Application Services LLC Limited Liability Company 34538 County Road 13 Westbrook MN 56183 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-08 Benjamin Olsem oaasllc@gmail.com Westbrook Cottonwood MN Megan Olsem Tobin Richards Signed (1) The employer does not elect the employers’ liability coverage. Benjamin Olsem oaasllc@gmail.com Owner/Self Westbrook Cottonwood MN Megan Olsem Tobin Richards Signed
529 2021-05-24 16:16 Anonymous (not verified) 67.230.239.111 Olsem Aerial Application Services LLC Limited Liability Company 34538 County Road 13 Westbrook, Minnesota 56183 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-24 Benjamin Olsem oaasllC@gmail.com Westbrook Cottonwood Minnesota Megan Olsem Jeff Oberg Signed (1) The employer does not elect the employers’ liability coverage. Olsem Aerial Application Services LLC oaasllc@gmail.com Owner/Self Westbrook Cottonwood Minnesota Megan Olsem Jeff Oberg Signed
1394 2022-12-14 14:31 Anonymous (not verified) 74.84.121.206 Benjamin Salo Proprietorship 320 Plat St Lansing, IA 52151 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-09 Benjamin Salo benwa011@gmail.com Lansing, Iowa Allamakee Iowa Chris Fye Darrel Elsbernd Signed (1) The employer does not elect the employers’ liability coverage. Benjamin Salo benwa011@gmail.com self Lansing Allamakee Iowa Chris Fye Darrel Elsbernd Signed
896 2022-02-04 11:58 Anonymous (not verified) 198.167.180.146 Northtowne Market Lot 7, LLC Limited Liability Company 1005 Blairs Ferry Road NE, Cedar Rapids, IA 52404 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Benjamin Wickum bwickum@collinscu.org CEDAR RAPIDS Linn Iowa Jody Comried Pat Milke Signed (1) The employer does not elect the employers’ liability coverage. Benjamin Wickum bwickum@collinscu.org Manager Cedar Rapids Linn Iowa Jody Comried Pat Milke Signed
702 2021-11-01 09:23 Anonymous (not verified) 173.28.195.56 Garcia Snow Removal Limited Liability Company 213 E 7th Street, West Liberty, Iowa 52776 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-01 Benji A Garcia garciabenji23@gmail.com West Liberty IA Norway Luis Ordenana-Choez Vicente Garcia Signed (1) The employer does not elect the employers’ liability coverage. Benji Garcia garciabenji23@gmail.com Member West Liberty Muscatine Iowa Luis Ordenana-Choez Vicente Garcia Signed
264 2020-09-21 13:26 Anonymous (not verified) 107.77.173.3 JAG Painting Proprietorship 1423 Des Moines Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-21 Berenice S Silva berenicesssvaldes@gmail.com Des Moines Polk Iowa Luis Garcia Maria Salas Signed (1) The employer does not elect the employers’ liability coverage. Berenice S Silva berenicesssvaldes@gmail.com Owner Des Moines Polk Iowa Luis Garcia Maria Salas Signed
349 2020-12-31 17:37 Anonymous (not verified) 107.77.161.33 JAG Painting Proprietorship 1423 des moines street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-12-31 Berenice Silva berenicesssvaldes@gmail.com Des moines Polk IA Manuel Aguilar Luis Garcia Signed (1) The employer does not elect the employers’ liability coverage. Berenice Silva berenicesssvaldes@gmail.com Owner Des moines Polk Iowa Manuel Aguilar Luis Garcia Signed
212 2020-07-20 16:43 Anonymous (not verified) 97.64.164.30 Bernard L. Gradoville D.D.S. Proprietorship 2800 Ingersoll Ave. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-20 Bernard Gradoville bgradoville@ingersollfamilydentistry.com Des Moines IA United States Tricia Wilson Jack Gradoville Signed (1) The employer does not elect the employers’ liability coverage. Bernard Gradoville bgradoville@ingersollfamilydentistry.com self Des Moines IA United States Tricia Wilson Jack Gradoville Signed
551 2021-06-29 09:18 Anonymous (not verified) 72.168.160.90 BERNARD WATERBECK Limited Liability Company 1353 280TH STREET, GARWIN, IOWA 50632 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-29 BERNARD WATERBECK garwinacres2012@hotmail.com GARWIN TAMA IOWA DEAN KELLER CESAR MARROQUIN Signed (1) The employer does not elect the employers’ liability coverage. BERNARD WATERBECK garwinacres2012@hotmail.com SAME PERSON GARWIN TAMA IOWA DEAN KELLER CESAR MARROQUIN Signed
1430 2023-01-25 14:50 Anonymous (not verified) 104.222.82.50 Pille Ceramic Tile Proprietorship 17645 Guthrie 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. 2023-01-25 Bernie Pille blpille@yahoo.com Maple River Carroll IA Lisa Pille None Signed (1) The employer does not elect the employers’ liability coverage. Bernie Pille blpille@yahoo.com Self Maple River Carroll IA Lisa Pille Cameron Pille Signed
682 2021-10-19 16:15 Anonymous (not verified) 65.144.174.26 BBR Tile and Professional Installation LLC Proprietorship 903 School Ave 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. 2021-10-19 Bertin Baltazar baltarey2009@gmail.com Norwalk Warren Iowa Enedelia Bonilla Fernando Garcia Signed (1) The employer does not elect the employers’ liability coverage. Bertin Baltazar baltarey2009@gmail.com Owner Norwalk Warren Iowa Enedelia Bonilla Fernando Garcia Signed
391 2021-02-10 14:27 Anonymous (not verified) 173.24.190.134 King Excavation, LLC Limited Liability Company 5343 410th St, Cylinder IA 50528 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-03 Beth King aletha1949@ncn.net Cylinder Palo Alto Iowa Candie Clark Dave Walters Signed (1) The employer does not elect the employers’ liability coverage. Beth King aletha1949@ncn.net Member of LLC Cylinder Palo Alto Iowa Candie Clark Dave Walters Signed
169 2020-05-28 11:31 Anonymous (not verified) 173.31.147.225 RECYCLED SPIRITS LLC Limited Liability Company 43 ANN ST MILFORD IA 51351 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-28 BETH LAMB BLAMB@SPENCERSCHOOLS.ORG MILFORD DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. BETH LAMB BLAMB@SPENCERSCHOOLS.ORG SELF MILFORD DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
997 2022-03-23 06:15 Anonymous (not verified) 167.142.233.235 Betsy Harms Agency LLC Limited Liability Company 101 Sherman Ave, Ackley, IA 50601 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-23 Betsy Harms bharms@phillipsstafford.com Ackley Franklin IA Levi Harms Patricia Harms Signed (1) The employer does not elect the employers’ liability coverage. Betsy Harms bharms@phillipsstafford.com Self Ackley Franklin IA Levi Harms Patricia Harms Signed
2100 2024-03-17 12:36 Anonymous (not verified) 94.188.205.167 Donovan Electric LLC Limited Liability Company 857 Tipperary rd Iowa City 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. 2024-03-17 Bill Donovan bill@donovanelectricllc.com Iowa City Johnson IA Bo Nock Stephanie Ineichen Signed (1) The employer does not elect the employers’ liability coverage. Blake Donovan blaked@donovanelectricllc.com Partner Iowa City Johnson IA Bo Nock Stephanie Ineichen Signed
1299 2022-09-07 14:55 Anonymous (not verified) 167.142.60.66 Harleen Trenching Proprietorship 2066 X Ave, Madrid Iowa 50156 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-07 Bill Harleen sandyharleen@hotmail.com Madrid Boone Iowa Thomas H Andersen Dustin T Andersen Signed (1) The employer does not elect the employers’ liability coverage. Bill Harleen Harleentrenching@hotmail.com Self Madrid Boone Iowa Thomas H Andersen Dustin T Andersen Signed
1352 2022-10-31 19:35 Anonymous (not verified) 173.17.8.56 Hutch's Parking Lot Sweeping INC Limited Liability Company 5235 JENNIFER DR I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-31 Bill HUTCHINSON btnwhutch@aol.com PLEASANT HILL Iowa United States TRACY HUTCHINSON NIC HUTCHINSON Signed (1) The employer does not elect the employers’ liability coverage. Bill HUTCHINSON btnwhutch@aol.com SELF PLEASANT HILL Iowa United States TRACY HUTCHINSON NIC HUTCHINSON Signed
2176 2024-04-24 11:12 Anonymous (not verified) 94.188.205.176 Schutters Pest Control Inc. Limited Liability Company 109 2nd Ave, Suite #2, Carbon Cliff,IL 61239 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-04 Billy Y Schutters schutterspestcontrol@gmail.com Bettendorf Iowa United States Aidan Sammon Kalissa Malin Signed (1) The employer does not elect the employers’ liability coverage. Billy Y Schutters schutterspestcontrol@gmail.com Same Person Carbon Cliff Rock Island Illinois Aidan Sammon Kalissa Malin Signed
2168 2024-04-22 08:18 Anonymous (not verified) 94.188.207.228 Mattson's Floor Covering Proprietorship 2073 Sandy Lane I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-22 Blaine Linn Mattson tmatzan99@yahoo.com Oquawka Henderson Illinois Cheryl Ross Larry Rheinschmidt Signed (1) The employer does not elect the employers’ liability coverage. Blaine Mattson tmatzan22@yahoo.com owner Oquawka Henderson Illinois Cheryl Ross Larry Rheinschmidt Signed
101 2020-03-24 15:49 Anonymous (not verified) 161.69.123.10 Blair Lincoln Proprietorship 32586 390th St Colesburg, IA 52035 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-24 Blair Alan Lincoln balincoln@gmail.com Colesburg County Iowa Brandon Mather Travis Ries Signed (1) The employer does not elect the employers’ liability coverage. Blair Alan Lincoln balincoln@gmail.com Owner Colesburg County IA Brandon Mather Travis Ries Signed
1357 2022-11-03 15:06 Anonymous (not verified) 66.129.196.99 Blake Carson Limited Liability Company 1550 plainview rd ely, IA 52227 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-21 Blake Dennis Carson Blake@carsondesignsco.com Ely Linn iowa Dennis Carson Jordan Mellinger Signed (1) The employer does not elect the employers’ liability coverage. Blake Carson Blake@carsondesignsco.com member/Owner Ely linn iowa Dennis Carson Jordan Mellinger Signed
1975 2024-01-04 15:42 Anonymous (not verified) 94.188.207.229 Blake S. Judisch Masonry LLC Limited Liability Company 510 South Fulton St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-04 Blake Judisch blakejudisch@gmail.com Shell rock Butler IA Kali Judisch Terri Thomsen Signed (1) The employer does not elect the employers’ liability coverage. Blake Judisch blalejudisch@gmail.com Owner Shell rock Butler IA Kali Judisch Terri Thomsen Signed
604 2021-08-14 11:18 Anonymous (not verified) 69.54.119.134 Robert Curry Limited Liability Company 10759 S 96th Ave W Prairie City IA 50228 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-14 Bob Curry Gardengal4205@gmail.com Prairie City IA United States Megan Irwin Rob Irwin Signed (1) The employer does not elect the employers’ liability coverage. Robert Curry Gardengal4205@gmail.com Self Prairie City IA United States Megan Irwin Rob Irwin Signed
759 2021-11-19 18:54 Anonymous (not verified) 173.23.148.83 EFP Construction Limited Liability Company 1825 East Grand Ave Des Moines, Iowa 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-19 Bobby Perry efpconstruction21@gmail.com Des Moines Polk Iowa Tanya Perry Megan McIlhon Signed (1) The employer does not elect the employers’ liability coverage. Bobby Perry efpconstruction21@gmail.com Self Des Moines Polk Iowa Tanya Perry Megan McIlhon Signed
1451 2023-02-13 13:27 Anonymous (not verified) 94.188.205.168 Better Built Floors, LLC Limited Liability Company 950 Spruce street Waukee, IA, 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-13 Bodhi Cox betterbuiltfloors@gmail.com waukee dallas iowa Bodhi Cox Daniel Cox Signed (1) The employer does not elect the employers’ liability coverage. Bodhi Cox betterbuiltfloors@gmail.com i am thge owner/operator waukee dallas iowa Bodhi Cox Daniel Cox Signed
1974 2024-01-04 13:12 Anonymous (not verified) 94.188.205.167 Cro Outdoor Services, LLC Limited Liability Company 1616 NW 78TH 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. 2023-12-20 Bojan Djukic Croodsia@gmail.com Clive Iowa United States Cezar Villalobos Maria Villalobos Signed (1) The employer does not elect the employers’ liability coverage. Evetee Villalobos e.villalobos91@gmail.com s/o Clive IA United States Maria Villalobos Cezar Villalobos Signed
1029 2022-04-04 12:46 Anonymous (not verified) 174.215.242.124 Bonnie Seely Proprietorship 43 rainbow court se Cedar Rapids Iowa 52403 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-04 Bonnie Elizabeth seely bseely4@gmail.com Cedar Rapids Linn Iowa Mikaela Seely Noah seely Signed (1) The employer does not elect the employers’ liability coverage. Bonnie Seely bseely4@gmail.com Self Cedar Rapids IA United States Mikaela Seely Noah Seely Signed
1077 2022-04-28 13:16 Anonymous (not verified) 149.20.212.228 Van Ginkel Farms LLC Limited Liability Company 2745 Chestnut Ave Inwood, IA 51240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-14 Bonnie VanGinkel bonnievanginkel@gmail.com Inwood Lyon Iowa Jesse Niemeyer Jaslyn VanOtterloo Signed (1) The employer does not elect the employers’ liability coverage. James VanGinkel bonnievanginkel@gmail.com owner Inwood Lyon Iowa Jesse Niemeyer Jaslyn VanOtterloo Signed
1262 2022-08-16 12:52 Anonymous (not verified) 74.137.151.70 Golds Custom Grading LLC Limited Liability Company Po Box 114 Spencer, IA 51301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-16 Brad Carlson brad_carlson@gmail.com Spencer Clay Iowa Thomas Dunn Nancy Cassa Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Thomas Dunn TDUNN@THOMASBRADLEYINSURANCE.COM Agent Madison Dane Wisconsin Nancy Cassa Brad Carlson Signed
431 2021-03-10 14:41 Anonymous (not verified) 66.188.136.150 Brad Donovan Proprietorship 1105 N 5th. Springfield, IL 62702 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-10 Brad Donovan braddonovan40@gmail.com Springfield Sangamon IL Russell Masartis Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Brad Donovan braddonovan40@gmail.com Same Springfield Sangamon IL Russell Masartis Shuree Behr Signed
471 2021-04-13 10:35 Anonymous (not verified) 65.103.82.36 River City Floors Proprietorship 2114 N Zenith Ave Davenport IA 52804 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-30 Brad Ernest Dahl na@noemail.com Davenport Scott IA Dawn T Ben S Signed (1) The employer does not elect the employers’ liability coverage. Brad Dahl na@noemail.com Owner Davenport Scott IA Dawn T Ben S Signed
1116 2022-05-17 21:41 Anonymous (not verified) 75.162.182.172 Hinds Metal Designs LLC Limited Liability Company 11409 Dakota 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. 2022-05-18 Brad Hinds bahinds@msn.com Norwalk Iowa Iowa Trevor Masten Travis Masten Signed (1) The employer does not elect the employers’ liability coverage. Carlene Hinds carlene4082@msn.com Self Norwalk Iowa Iowa Trevor Masten Travis Masten Signed
1354 2022-11-01 05:31 Anonymous (not verified) 75.162.229.216 Brad Sommers Construction, LLC. Limited Liability Company 23653 N Ave, Dallas Center, Iowa 50063 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-31 Brad Sommers Bsconst1@gmail.com Dallas Center Dallas Iowa Ben Sommers Keith Winey Signed (1) The employer does not elect the employers’ liability coverage. Brad Sommers Bsconst1@gmail.com owner Dallas Center Dallas Iowa Ben Sommers Keith Winey Signed
832 2022-01-12 17:23 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 Braden L Gray grayb2014@gmail.com Cedar Falls Black Hawk County Iowa Kari Houle Darren Dean Fanning 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 Darren Dean Fanning Signed
1721 2023-07-06 08:19 Anonymous (not verified) 94.188.207.228 Bradford Alexander Carr Proprietorship 3349 Southgate Ct SW Ste 101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Bradford Alexander Carr alex.carr@thrivent.com Coralville Johnson Iowa Gaylon Heetland David King Signed (1) The employer does not elect the employers’ liability coverage. Bradford Alexander Carr alex.carr@thrivent.com Self Coralville Johnson Iowa Gaylon Heetland David King Signed
1830 2023-09-08 11:45 Anonymous (not verified) 94.188.205.177 Bradley A Sneeden Proprietorship 36 Sunset Drive, Beardstown, IL 62618 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-08 Bradley A Sneeden bradsneeden@gmail.com Beardstown Cass IL Billie Sneeden Dillon McNeff Signed (1) The employer does not elect the employers’ liability coverage. Bradley A Sneeden bradsneeden@gmail.com Self Beardstown Cass IL Billie Sneeden Dillon McNeff Signed
1636 2023-05-10 07:31 Anonymous (not verified) 94.188.205.167 Brad Bower Drywall LLC Limited Liability Company 209 Northridge West Branch, IA 52358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-10 Bradley Bower bbower74@gmail.com West Branch Cedar Iowa Kirk Strunk Chris Hay Signed (1) The employer does not elect the employers’ liability coverage. Brad Bower bbower74@gmail.com Self West Branch Cedar Iowa Kirk Strunk Chris Hay Signed
944 2022-03-03 13:54 Anonymous (not verified) 192.95.125.191 B&R Enterprises LLC Limited Liability Company 2850 73rd St., Newhall, IA 52315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-02-17 Bradley Rick ashlyn@3riversins.net Newhall Benton Iowa Ashlyn Christianson Angie McFarland Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Ronald Jarrett brsirenguys@gmail.com LLC Member Newhall Benton Iowa Ashlyn Christianson Angie McFarland Signed
1223 2022-07-22 15:14 Anonymous (not verified) 167.142.255.81 HomeOwner's Helper LLC Limited Liability Company 111 4th Ave, Underwood, IA 51576 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Bradley W Syndergaard mrslouie8@yahoo.com UNDERWOOD Iowa United States Stacy L Louison Brent C Louison Signed (1) The employer does not elect the employers’ liability coverage. Bradley W Syndergaard mrslouie8@yahoo.com Self UNDERWOOD Iowa United States Stacy L Louison Brent C Louison Signed
1779 2023-08-03 15:40 Anonymous (not verified) 94.188.207.224 Action Garage Builders Limited Liability Company 1635 Kerry Lane, Jesup, IA 50648 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-03 Brady Huls brady.cve@gmail.com Cedar Falls Black Hawk Iowa Tyler Reynolds Joshua Carder Signed (1) The employer does not elect the employers’ liability coverage. Troy Even actiongaragebuilders@gmail.com Owner Jesup Buchanan Iowa Tyler Reynolds Joshua Carder Signed
1730 2023-07-09 23:39 Anonymous (not verified) 94.188.207.225 Steffens Constuction Proprietorship 68222 Lansing Road, Wiota, IA 50274 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Bradyn Richard Steffens steffens4211@gmail.com Wiota Cass Iowa Katrina Sonntag Chris Obrien Signed (1) The employer does not elect the employers’ liability coverage. Audra Kelley Steffens steffens4211@gmail.com wife Wiota Cass Iowa Katrina Sonntag Chris Obrien Signed
1604 2023-04-26 09:03 Anonymous (not verified) 94.188.207.225 LeafHome Solutions LLC Limited Liability Company 3060 SE Grimes Boulevard 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. 2023-04-26 Braedyn Baylor bbaylor66@gmail.com West des moines Polk Iowa Cassidy Tolle Jeffrey Baylor Signed (1) The employer does not elect the employers’ liability coverage. Braedyn Baylor bbaylor66@gmail.com Self West Des Moines Polk Iowa Julie Baylor Brianna Stephens Signed
1605 2023-04-26 09:48 Anonymous (not verified) 94.188.207.229 Double Barrell Construction Proprietorship 1237 S 52nd St, #804, West Des Moines, IA 50265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-26 Braedyn Baylor bbaylor66@gmail.com West Des Moines Polk IA Peggy Toft Rick Thompson Signed (1) The employer does not elect the employers’ liability coverage. Braedyn Baylor bbaylor66@gmail.com Owner West Des Moines Polk IA Peggy Toft Rick Thompson Signed
102 2020-03-25 11:23 Anonymous (not verified) 206.72.14.249 Brandi Wehr Proprietorship 123 E Marion St, Sigourney, IA 52591 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-25 Brandi Jo Wehr brndwehr54@hotmail.com Sigourney Keokuk Iowa Amber Kephart Mary Beth Knipfer Signed (1) The employer does not elect the employers’ liability coverage. Chelsea Voss chelsea@grimmrealestate.com Agent North English Iowa Iowa Amber Kephart Mary Beth Knipfer Signed
89 2020-03-13 12:41 Anonymous (not verified) 216.96.113.16 B’s Sweet Treats Proprietorship 123 E Marion St. Sigourney IA 52591 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-13 Brandi Wehr brndwehr54@hotmail.com Sigourney Keokuk IA Brandi Brandi Signed (1) The employer does not elect the employers’ liability coverage. Brandi Wehr brndwehr54@hotmail.com Same Sigourney Keokuk IA Brandi Brandi Signed
99 2020-03-23 16:47 Anonymous (not verified) 216.96.116.78 B’s Sweet Treats Proprietorship 21484 196th 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. 2020-03-23 Brandi Wehr brndwehr54@hotmail.com Sigourney Keokuk IA Erik Wehr Brenda Workman Signed (1) The employer does not elect the employers’ liability coverage. Brandi Wehr brndwrhr54@hotmail.com Self Sigourney Keokuk IA Brenda Workman Erik Wehr Signed
289 2020-10-23 14:42 Anonymous (not verified) 65.103.82.36 Go Green Lawn and Tree Proprietorship 2911 N Harrison st Davenport IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-23 Brandon gogreenlawnandtree@yahoo.com davenport scott iowa Kayla Artioli Eric Johnson Signed (1) The employer does not elect the employers’ liability coverage. brandon gordon gogreenlawnandtree@yahoo.com self davenport scott ia kayla eric Signed
502 2021-05-04 12:56 Anonymous (not verified) 75.89.78.95 HENNICK TREE SERVICE LLC Limited Liability Company 1852 MAINE RIDGE ROAD, CENTRAL CITY, IA 52214 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-05-04 BRANDON ALAN HENNICK hennicktreeservice@gmail.com CENTRAL CITY LINN IOWA KATHY RUTH WOOD ROBBIE WILLIAM WILLIS Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Brandon Hennick hennicktreeservice@gmail.com OWNER CENTRAL CITY IA United States KATHY RUTH WOOD ROBBIE WILLIAM WILLIS Signed
408 2021-02-18 10:51 Anonymous (not verified) 165.225.61.119 Brandon Anderson Painting Proprietorship 608 30th St Rock Island, IL 61201 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-21 Brandon Anderson banderson792@gmail.com Rock Island Rock Island IL Seth Rowland Jay Romeo Signed (1) The employer does not elect the employers’ liability coverage. Brandon Anderson banderson792@gmail.com Self Rock Island Rock Island IL Seth Rowland Jay Romeo Signed
1398 2022-12-21 22:02 Anonymous (not verified) 24.149.20.131 B's Lawn Care Limited Liability Company 1118 Rainbow Drive, Cedar Falls, Iowa 50613, United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-21 Brandon Ballenger lawncare.bee@gmail.com Cedar Falls Iowa United States Katie Ballenger Tyler Ballenger Signed (1) The employer does not elect the employers’ liability coverage. Brandon Ballenger lawncare.bee@gmail.com Owner/Operator Cedar Falls Iowa United States Katie Ballenger Tyler Ballenger Signed
2024 2024-02-06 20:31 Anonymous (not verified) 94.188.207.223 BTS Custom Floors Proprietorship 22 wenwood cir I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-06 Brandon Clay Brandon.btscustomfloors@gmail.com Council Bluffs Iowa United States Darin Thompson Amber Swanson Signed (1) The employer does not elect the employers’ liability coverage. Brandon Clay Brandon.btscustomfloors@gmail.com I am them Council Bluffs Iowa United States Amber Swanson Darin Thompson Signed
647 2021-09-20 10:37 Anonymous (not verified) 173.29.34.49 Brandon Jones Proprietorship 2043 3x Avenue I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-20 Brandon Dederick Jones Kaleb0430jones@gmail.com East Moline United States Illinois Brandon Jones Brandon Jones Signed (1) The employer does not elect the employers’ liability coverage. Brandon Dederick Jones Kaleb0430jones@gmail.com self East Moline United States Illinois Brandon Jones Brandon Jones Signed
849 2022-01-20 13:58 Anonymous (not verified) 50.82.130.211 Albatross Capital, LLC Limited Liability Company 28003 290th St., Parkersburg IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-22 Brandon Huisman cmins_re@mchsi.com Parkersburg Butler IA Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Brandon Huisman cmins_re@mchsi.com Member of LLC Parkersburg Butler IA Chad Campbell Roxanne Kolder Signed
505 2021-05-10 07:06 Anonymous (not verified) 69.63.16.2 Three Boys Contracting LLC Limited Liability Company 1108 Cullen Dr, 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. 2021-05-08 Brandon J Campbell threeboyscarpentry@gmail.com Tiffin Johnson Iowa Steve Fishman Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Brandon J Campbell threeboyscarpentry@gmail.com Managing Member Tiffin Johnson Iowa Steve Fishman Dyan Kriener Signed
1684 2023-06-09 14:42 Anonymous (not verified) 94.188.207.223 Brandon Thomas Proprietorship 1119 Curtiss Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-08 Brandon K Thomas Brandon.thomas@countitalljoy.com.mx Ames IA United States Leah Churchill George Trice Signed (1) The employer does not elect the employers’ liability coverage. Brandon K Thomas Brandon.thomas@countitalljoy.com.mx Same person Ames IA United States Leah Churchill George Trice Signed
144 2020-04-29 11:20 Anonymous (not verified) 65.158.103.107 Symbiotic Gardens LLC Limited Liability Company 3403 Dubuque Avenue Des Moines Iowa 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-29 Brandon Kam symbioticgardens@gmail.com Des Moines Polk Iowa Kathy Schulte Larry Johnson Signed (1) The employer does not elect the employers’ liability coverage. Brandon Kam symbioticgardens@gmail.com same Des Moines Polk Iowa Kathy Schulte Larry Johnson Signed
1642 2023-05-12 07:29 Anonymous (not verified) 94.188.205.169 HARI SWAMI LLC Limited Liability Company 2759 Mt Pleasant 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. 2023-05-12 BRANDON KELLY MARKWILLIAMSPRO@GMAIL.COM FRUIT HEIGHTS DAVIS UTAH MARK WILLIAMS GREG VANCAMP Signed (1) The employer does not elect the employers’ liability coverage. BRANDON KRLLY MARKWILLIAMSPRO@GMAIL.COM SELF FRUIT HEIGHTS DAVIS UTAH MARK WILLIAMS GREG VANCAMP Signed
2060 2024-02-28 09:36 Anonymous (not verified) 94.188.207.228 BRANDON LEHNER Proprietorship 308 SANFORD STREET ARCHER IA 51231 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-28 BRANDON LEHNER BLEHNER302@GMAIL.COM ARCHER OBRIEN IA TAMI KLEIN JOSEPH LORING Signed (1) The employer does not elect the employers’ liability coverage. BRANDON LEHNER BLEHNER302@GMAIL.COM SELF ARCHER OBRIEN IA TAMI KLEIN JOSEPH LORING Signed
1714 2023-06-27 09:14 Anonymous (not verified) 94.188.205.167 Meier Trucking LLC Limited Liability Company 35032 308th St, Bellevue, IA 52031 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-14 Brandon Meier meierturcking87@yahoo.com Bellevue Jackson Iowa Susan Miller Nicole Mensen Signed (1) The employer does not elect the employers’ liability coverage. Brandon Meier meiertrucking87@yahoo.com self Bellevue Jackson Iowa Susan Miller Nicole Mensen Signed
1282 2022-08-25 06:51 Anonymous (not verified) 63.240.136.241 River City Property Services LLC. Limited Liability Company 1936 9th 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. 2022-08-25 Brandon Smith RiverCityPropertyServices@outlook.com Camanche Iowa United States Sarah Smith MIke Burmahl Signed (1) The employer does not elect the employers’ liability coverage. Brandon Smith RiverCityPropertyServices@outlook.com Partner Camanche Iowa United States Sarah Smith MIke Burmahl Signed
836 2022-01-12 19:41 Anonymous (not verified) 170.178.244.191 BVH Trucking LLC Limited Liability Company 26826 210th Ave Eldridge IA 852748 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-12 Brandon Venhorst avenhorst@csteldridge.com Eldridge Scott IA Annette Venhorst Scott Venhorst Signed (1) The employer does not elect the employers’ liability coverage. Brandon Venhorst avenhorst@csteldridge.com Owner Eldridge Scott IA Annette Venhorst Scott Venhorst Signed
714 2021-11-05 11:16 Anonymous (not verified) 209.252.172.87 Branson Bult - Bults Flooring Proprietorship 440 Memorial Dr Se Cedar Rapids, Ia 52403 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-16 Branson Bult bultsfloorcovering@gmail.com Cedar Rapids Linn Iowa Heather Howell Sarah Coberley Signed (1) The employer does not elect the employers’ liability coverage. Branson Bult bultsfloorcovering@gmail.com Self Cedar Rapids Linn Iowa Heather Howell Sarah Coberley Signed
1295 2022-09-05 20:39 Anonymous (not verified) 173.30.59.248 Guide LLC Limited Liability Company 1655 Ashton Place, 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. 2022-09-05 Braydon Fisher braydonfisher28@gmail.com Dubuque IA United States Conner Cole Alec Kolander Signed (1) The employer does not elect the employers’ liability coverage. Braydon Fisher braydonfisher28@gmail.com Owner Dubuque IA United States Conner Cole Alex Kolander Signed
644 2021-09-17 11:20 Anonymous (not verified) 167.142.95.56 Preferred Properties of Iowa, Inc. Limited Liability Company 500 W. Temple St., Lenox, IA 50851 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-17 Brennan Kester mdpearson88@gmail.com Corning Taylor Iowa Ron Travis Maury Moore Signed (1) The employer does not elect the employers’ liability coverage. Dan Zech dan.ppi@gmail.com owner Lenox Taylor Iowa Ron Travis Maury Moore Signed
1265 2022-08-17 11:10 Anonymous (not verified) 166.181.81.66 Balvanz Electric Proprietorship 1517 Greenfield Dr I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-17 Brent Balvanz balvanzelectric@gmail.com Marshalltown Iowa Iowa Tawnya Dawson Phyllis Mazour Signed (1) The employer does not elect the employers’ liability coverage. Brent Balvanz balvanzelectric@gmail.com Self Marshalltown Iowa Iowa Tawnya Dawson Phyllis Mazour Signed
1266 2022-08-17 11:10 Anonymous (not verified) 166.181.81.66 Balvanz Electric Proprietorship 1517 Greenfield Dr I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-17 Brent Balvanz balvanzelectric@gmail.com Marshalltown Iowa Iowa Tawnya Dawson Phyllis Mazour Signed (1) The employer does not elect the employers’ liability coverage. Brent Balvanz balvanzelectric@gmail.com Self Marshalltown Iowa Iowa Tawnya Dawson Phyllis Mazour Signed
2179 2024-04-25 10:58 Anonymous (not verified) 94.188.205.177 Loonpa Landscaping LLC Limited Liability Partnership 5309 Red Oak Ln Cedar Falls, IA 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2024-04-25 Brent Barloon Brent@barerootslawn.care WAterloo Black Hawk Iowa James White Kari White Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Daniel White danny@barerootslawn.care Owner Cedar Falls Black Hawk Iowa James White Kari White Signed
878 2022-01-31 12:37 Anonymous (not verified) 63.152.234.243 It's a Breeze Cleaning Service Proprietorship 760 W 8th Ave, Marion, IA 52302 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-31 Breonna Kay Nelson breanderson82@yahoo.com Marion Linn Iowa Anna Walbridge Tyler Nelson Signed (1) The employer does not elect the employers’ liability coverage. Breonna Kay Nelson breanderson82@yahoo.com Self Marion Linn Iowa Anna Walbridge Tyler Nelson Signed
1400 2022-12-22 10:02 Anonymous (not verified) 166.196.110.105 It's a Breeze Cleaning Service Proprietorship 760 W 8th Ave Marion, IA 52302 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-22 Breonna Nelson breanderson82@yahoo.com Marion Linn Iowa Tyler Nelson Lisa Nelson Signed (1) The employer does not elect the employers’ liability coverage. Breonna Nelson Breanderson82@yahoo.com Self Marion Linn IA Tyler Nelson Lisa Nelson Signed
116 2020-04-09 11:45 Anonymous (not verified) 67.60.46.104 D&H Plumbing, L.L.C Limited Liability Company 44214 260th St. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-05 Brett Alan Herbold brettherbold@gmail.com Remsen Plymouth Iowa Doug Alan Gerdes Nick Willam Lahrs Signed (1) The employer does not elect the employers’ liability coverage. Delwayne Merrill Abbott brettherbold@gmail.com Owner Kinglsey Plymouth Iowa Doug Alan Gerdes Nick William Lahrs Signed
57 2020-02-10 15:33 Anonymous (not verified) 198.167.182.164 AllEnhancements LLC Limited Liability Company 1122 Woodland Ln, LeClaire, IA 52753 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-31 Brett Allen allenhancementsllc@outlook.com LeClaire Scott Iowa Steven J Fishman E Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Brett Allen allenhancementsllc@outlook.com Managing Member LeClaire Scott Iowa Steven J Fishman E Dyan Kriener Signed
157 2020-05-14 15:11 Anonymous (not verified) 173.28.28.57 Brett Dix Proprietorship 16696 245th Street, Aplington, IA 50604 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-30 Brett Dix cmins_re@mchsi.com Aplington Butler IA Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Brett Dix cmins_re@mchsi.com Self Aplington Butler IA Chad Campbell Roxanne Kolder Signed
727 2021-11-05 14:46 Anonymous (not verified) 174.198.66.202 Bret Swift Swift Enterprises Proprietorship 2240 Coldstream 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. 2020-01-13 Brett Swidt swiftenterprises@me.com Cedar Rapids Linn Iowa Sarah Coberley Heather Howell Signed (1) The employer does not elect the employers’ liability coverage. Bret Swift swiftenterprises@me.com Self Employed Cedar Rapids Linn Iowa Sarah Coberley Heather Howell Signed
176 2020-06-07 08:23 Anonymous (not verified) 174.16.51.128 TrueFood LLC Limited Liability Company 2055 Nature Ave Stanton IA 51573 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-24 Brian Barkman brian.barkman@truefood.farm Georgetown Williamson Texas Wanda Barkman Chelsea Church Signed (1) The employer does not elect the employers’ liability coverage. Brian Barkman brian.barkman@truefood.farm TrueFood LLC is owned by agent Stanton Montgomery IA Wanda Barkman Chelsea Church Signed
320 2020-11-17 10:08 Anonymous (not verified) 65.103.82.36 Brian Behnkendorf dba Dutchmen Services Proprietorship 55 Rose Court West, Geneseo IL 61254 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-13 Brian Behnkendorf 4gbbehnk@gmail.com Geneseo Henry Illinois Kayla Artioli Eric Johnson Signed (1) The employer does not elect the employers’ liability coverage. Brian Behnkendorf 4gbbehnk@gmail.com Self Geneseo Henry Illinois Kayla Artioli Eric Johnson Signed
1011 2022-03-28 10:25 Anonymous (not verified) 207.199.231.172 Brian Carmer Proprietorship 133 S Iowa Ave, Ottumwa, IA 52501 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-28 Brian Carmer b_carmer@yahoo.com Ottumwa Wapello Iowa James Anderson Ashley Bryan Signed (1) The employer does not elect the employers’ liability coverage. Brian Carmer B_Carmer@yahoo.com Self Ottumwa Wapello Iowa James Anderson Ashley Bryan Signed
200 2020-07-09 10:56 Anonymous (not verified) 167.142.98.40 brian chisum Proprietorship 168 c.r. 2007 valley view tx I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-09 brian chisum chisum413@gmail.com valley view cooke tx lakota larson john morland Signed (1) The employer does not elect the employers’ liability coverage. brian chisum chisum413@gmail.com self valley view cooke tx lakota larson john morland Signed
835 2022-01-12 17:41 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 Brian Christopher Armbruster crossespalms42@gmail.com Waterloo Black Hawk County Iowa Kari Houle Erik Bjorn Nelson 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 Erik Bjorn Nelson Signed
854 2022-01-24 19:59 Anonymous (not verified) 217.180.228.216 Hansen Installations Limited Liability Company 109 NW Calista Ct. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-24 Brian D Hansen bdhansen33@gmail.com Grimes IA United States Laurie Mills Jaiden Nelson Signed (1) The employer does not elect the employers’ liability coverage. Brian D Hansen bdhansen33@gmail.com Self Grimes IA United States Laurie Mills Jaiden Nelson 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
1043 2022-04-12 18:20 Anonymous (not verified) 66.129.218.53 DON'S LOCK & SAFE LLC Proprietorship 4223 YVETTE ST SUITE 101, IOWA CITY, IA 52240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-12 BRIAN E LOUGH LOLOCK@LIVE.COM NORTH LIBERTY JOHNSON IOWA WILLIAM H CRILE KELLI L SCOTT Signed (1) The employer does not elect the employers’ liability coverage. BRIAN E LOUGH LOLOCK@LIVE.COM OWNER NORTH LIBERTY JOHNSON IA WILLIAM H CRILE KELLI L SCOTT Signed
1428 2023-01-23 19:31 Anonymous (not verified) 206.72.6.241 Brian Grote Limited Liability Company 919 Highway 37 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-23 Brian Grote grote919@gmail.com Earling Iowa United States Jaurel Grote Dan Grote Signed (1) The employer does not elect the employers’ liability coverage. Leinen Construction grote919@gmail.com sub Harlan Iowa Iowa United States Jaurel Grote Dan Grote Signed
946 2022-03-04 10:43 Anonymous (not verified) 173.26.213.159 InTuition Painting & Design Proprietorship 2244 East 46th Place Davenport Iowa, 52807 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Brian J Bourke brianbourke@mediacombb.net Davenport Scott IA Anna E. Bourke Nicole K. Bourke Signed (1) The employer does not elect the employers’ liability coverage. Brian Bourke intuitionpainting@mediacombb.net Self Davenport Iowa Scott Iowa Nicole K. Bourkeq Anna E. Bourke Signed
546 2021-06-22 15:41 Anonymous (not verified) 208.95.1.97 BAJ FLOORING, LLC Limited Liability Company 31533 CASTLE COURT, DYERSVILLE, IA. 52040 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-06-11 BRIAN JACQUE jacquebrian18@gmail.com DYERSVIILLE DUBUQUE IOWA STEPHEN J. SCHLUETER PAULA FITZGERALD Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. BRIAN JACQUE jacquebrian18@gmail.com LLC MEMBER DYSERSVILLE DUBUQUE IOWA STEPHEN J. SCHLUETER PAULA FITZGERALD Signed
633 2021-09-08 10:35 Anonymous (not verified) 208.95.1.97 BAJ Flooring, LLC Limited Liability Company 31533 Castle Ct. Dyersville, IA. 52040-7600 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-09-08 Brian Jacque JacqueBrian18@gmail.com Dyersville Dubuque Iowa Stephen J. Schluter Paula Fitzgerald Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Brian A. Jacque JacqueBrian18@gmail.com LLC MEMBER Dyersville DUBUQUE IOWA Stephen J. Schlueter Stephen J. Schlueter Signed
184 2020-06-12 10:38 Anonymous (not verified) 174.243.112.246 brian kass Proprietorship 15064 kass road I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-11 brian kass kass5kass@hotmail.com dubuque Iowa Iowa kelly kass jenny McIntyre Signed (1) The employer does not elect the employers’ liability coverage. brian kass kass5kass@hotmail.com self dubuque Iowa iowa Kelly Kass Jenny McIntyre Signed
1911 2023-11-15 20:39 Anonymous (not verified) 94.188.205.174 Bkauzie-LLC dba CR Painting Limited Liability Company 3051 104th St Suite A Urbandale IA 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-15 Brian Kauzlarich brian@crpaintingdsm.com Altoona Polk Iowa Ryan Thompson Rylie Thompson Signed (1) The employer does not elect the employers’ liability coverage. Brian Kauzlarich brian@crpaintingdsm.com owner/self Altoona Polk Iowa Ryan Thompson Rylie Thompson Signed
1881 2023-10-26 14:10 Anonymous (not verified) 94.188.205.175 McAninch Painting LLC Limited Liability Company 2422 Richmond Ave. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-26 Brian McAninch brian@allcoatfinishes.com Des Moines Polk Iowa Kane Fairman Brad Sandstoe Signed (1) The employer does not elect the employers’ liability coverage. Brian McAninch brian@allcoatfinishes.com Self Des Moines polk Iowa Kane Fairman Brad Sandstoe Signed
143 2020-04-29 09:59 Anonymous (not verified) 173.29.234.11 Plum Communications, LLC Limited Liability Company 1018 NW Campus Ridge Court I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-29 Brian Shearer brian@plumllc.com Ankeny Polk Iowa Kathryn Shearer Emily Davis Signed (1) The employer does not elect the employers’ liability coverage. Brian Dean Shearer brian@plumllc.com Self Ankeny Polk Iowa Kathryn Shearer Emily Davis Signed
350 2021-01-04 09:35 Anonymous (not verified) 173.29.234.11 Plum Communications, LLC Limited Liability Company 1018 NW Campus Ridge CT, 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. 2021-01-01 Brian Shearer brian@plumllc.com Ankeny Polk IA Brian Shearer Brian Shearer Signed (1) The employer does not elect the employers’ liability coverage. Brian Shearer brian@plumllc.com Owner Ankeny Polk IA Brian Shearer Brian Shearer Signed
823 2022-01-05 16:35 Anonymous (not verified) 173.29.232.165 Plum Communications, LLC Limited Liability Company 1018 NW Campus Ridge CT, 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. 2022-01-01 Brian Shearer brian@plumllc.com Ankeny Polk Iowa Brian Shearer Brian Shearer Signed (1) The employer does not elect the employers’ liability coverage. Brian Shearer brian@plumllc.com Owner Ankeny Polk IA Brian Shearer Brian Shearer Signed
1747 2023-07-14 12:18 Anonymous (not verified) 94.188.207.224 WIL-EQUIPMENT Limited Liability Company 16400 Highway 92 Indianola Iowa 50125 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-14 Brian Wilson wileq@outlook.com Indianola Warren Iowa Linda Jill Wilson Megan Elizabeth Wilson Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Brian Wilson wileq@outlook.com Owner of Business Indianola Iowa United States Linda Jill Wilson Megan Elizabeth Wilson Signed
1434 2023-01-31 07:12 Anonymous (not verified) 162.233.75.173 abc Proprietorship 1122 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-31 Brian Yurko byurko714@gmail.com Cedar Falls Black Hawk Iowa pete re pete Signed (1) The employer does not elect the employers’ liability coverage. LHE byurko@leafhome.com contractor Deerfield Beach Florida United States pete re pete Signed
1482 2023-02-24 13:57 Anonymous (not verified) 94.188.205.175 Vaughn Seeds, LLC Limited Liability Company 5025 13th Ave, La Porte City, IA 50651 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-24 Brice Jacob Vaughn brice.vaughn1@gmail.com La Porte Citty Benton Iowa Abby Jo Rolston Jessica Lyn McCabe Signed (1) The employer does not elect the employers’ liability coverage. Abby Rolston arolston@hagerins.net Insured La Porte City Black Hawk Iowa Jessica Lyn McCabe Russell Britson Signed
12 2019-12-17 19:54 Anonymous (not verified) 50.83.188.192 B & B Construction Proprietorship 2463 93rd Avenue Norwalk, IA 50211 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-12-17 Brock A Maxwell brock246393@gmail.com Des Moines IA United States Hope Winegardner Yvonne Ginther Signed (1) The employer does not elect the employers’ liability coverage. Brock A Maxwell brock246393@gmail.com Owner Des Moines POlK Iowa Yvonne Ginther Hope Winegardner Signed
201 2020-07-09 11:07 Anonymous (not verified) 167.142.98.40 Brock Chisum Proprietorship 369 Wise Rd., Decatur, TX76234 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-09 Brock Chisum bchisum@hotmail.com Decatur, TX Wise Texas Lakota Larson Ryan Stott Signed (1) The employer does not elect the employers’ liability coverage. Brock Chisum bchisum@hotmail.com Self Decatur Wise Texas Lakota Larson Ryan Stott Signed
1140 2022-06-02 21:20 Anonymous (not verified) 167.142.38.107 BV Transport LLC Limited Liability Company 3406 150th 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. 2022-06-02 Brody Joseph Vaske Brody.vaske44@gmail.com Bancroft IA United States Ed Goche Kelly Deitering Signed (1) The employer does not elect the employers’ liability coverage. Brody Vaske Brody.vaske44@gmail.com Self Bancroft IA United States Ed Goche Kelly Deitering Signed
1148 2022-06-08 11:41 Anonymous (not verified) 70.96.153.153 Brody Willet LLC Limited Liability Company 244 #rd Ave N, Alburnett, IA 52202 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-08 Brody Willet brody@optionsexteriors.com Alburnett Linn County Iowa Charlotte Rasmussen Austin Miller Signed (1) The employer does not elect the employers’ liability coverage. Brody Willet brody@optionsexteriors.com Owner Alburnett Linn County Iowa Charlotte Rasmussen Austin Miller Signed
1455 2023-02-15 11:44 Anonymous (not verified) 94.188.205.177 Bruce A. Nelson Proprietorship 300 Shetland Dr Nw Cedar Rapids, IA 52405 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-15 Bruce A. Nelson sherylnelson15@yahoo.com Cedar Rapids Linn Iowa Lynn M Haigh David Reibsamen Signed (1) The employer does not elect the employers’ liability coverage. Sheryl Nelson sherylnelson15@yahoo.com Wife Cedar Rapids Linn Iowa Lynn M. Haigh David Reibsamen Signed
1332 2022-10-12 20:44 Anonymous (not verified) 209.252.174.114 Nelson Tile Proprietorship 300 Shetland Dr. N.W. Cedar Rapids, Ia. 52405 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-12 Bruce Allen Nelson sherylnelson15@yahoo.com Cedar Rapids Linn Iowa Sheryl Marie Nelson Roger Eugene Nelson Signed (1) The employer does not elect the employers’ liability coverage. Bruce Allen Nelson sherylnelson@yahoo.com Owner,operator / same Cedar Rapids Linn Iowa Sheryl Marie Nelson Roger Eugene Nelson Signed
576 2021-07-14 18:13 Anonymous (not verified) 69.169.10.40 J&M Excavation Inc. Limited Liability Company 411 Pine Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-14 Bruce Bilyeu jmexcavation@outlook.com Norwalk Warren IA Mike Petersen Dennis Bilyeu Signed (1) The employer does not elect the employers’ liability coverage. Bruce Bilyeu jmexcavation@outlook.com Owner Norwalk Warren IA Mike Petersen Dennis Bilyeu Signed
2177 2024-04-24 13:50 Anonymous (not verified) 94.188.205.175 Epic Tile and Bathroom Remodeling Proprietorship 815 Isett Ave Wapello, IA 52653 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-24 Bruce Conrad Briggs epictileiowa@gmail.com Wapello Louisa Iowa Cheryl Ross Larry Rheinschmidt Signed (1) The employer does not elect the employers’ liability coverage. Bruce Conrad Briggs epictileiowa@gmail.com owner Wapello Louisa Iowa Cheryl Ross Larry Rheinschmidt Signed
313 2020-11-11 20:35 Anonymous (not verified) 174.198.78.148 Wilson Snow Maintenance Proprietorship 3518 183rd Avenue, Carlisle, Iowa 50047 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-11 Bruce E. Wilson bewilson83@gmail.com Carlisle Warren Iowa Kristen Wilson Garett Wilson Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Bruce Wilson bewilson83@gmail.com self Carlisle Warren Iowa Kristen Wilson Garett Wilson Signed
1302 2022-09-11 22:05 Anonymous (not verified) 174.198.65.241 Bruce g Sellner Proprietorship 40998 597th ave new ulm mn 56073 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-11 Bruce g Sellner bgsellner74@gmail.com New ulm Nicollet Minnesota Carol m aura Steve l griebel Signed (1) The employer does not elect the employers’ liability coverage. Bruce g Sellner bgsellner74@gmail.com Owner New ulm Nicollet Mn Carol m aura Steve l griebel Signed
1303 2022-09-11 22:05 Anonymous (not verified) 174.198.65.241 Bruce g Sellner Proprietorship 40998 597th ave new ulm mn 56073 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-11 Bruce g Sellner bgsellner74@gmail.com New ulm Nicollet Minnesota Carol m aura Steve l griebel Signed (1) The employer does not elect the employers’ liability coverage. Bruce g Sellner bgsellner74@gmail.com Owner New ulm Nicollet Mn Carol m aura Steve l griebel Signed
1304 2022-09-11 22:05 Anonymous (not verified) 174.198.65.241 Bruce g Sellner Proprietorship 40998 597th ave new ulm mn 56073 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-11 Bruce g Sellner bgsellner74@gmail.com New ulm Nicollet Minnesota Carol m aura Steve l griebel Signed (1) The employer does not elect the employers’ liability coverage. Bruce g Sellner bgsellner74@gmail.com Owner New ulm Nicollet Mn Carol m aura Steve l griebel Signed
1869 2023-10-17 00:59 Anonymous (not verified) 94.188.207.230 Lisa's Janitorial Limited Liability Company 406 S. 10th Street Sac City, Iowa 50583 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Bruce Homer bhjhomer69@gmail.com Sac City Sac Iowa Autumn Simonsen Misty Brewster Signed (1) The employer does not elect the employers’ liability coverage. Bruce Homer bhjhomer69@gmail.com Self Sac City Sac Iowa Autumn Simonsen Misty Brewster Signed
1035 2022-04-05 12:03 Anonymous (not verified) 199.120.121.97 Bruce Peters Painting Proprietorship 53568 Rosewood Road, Walnut IA 51577 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-05 Bruce Peters bpeters1992@yahoo.com Walnut Pottawattamie Iowa Marie Peters Angie Gettys Signed (1) The employer does not elect the employers’ liability coverage. Bruce Peters bpeters1992@yahoo.com self Walnut Pottawattamie Iowa Marie Peters Angie Gettys Signed
1149 2022-06-09 17:43 Anonymous (not verified) 174.235.192.238 Bryan Linares Limited Liability Company 630 Hawthorne 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. 2022-06-09 Bryan Linares bryan.linares7798@gmail.com Crete Saline Nebraska Bryan Linares Chris Linares Signed (1) The employer does not elect the employers’ liability coverage. Christopher Linares chris5linares1995@gmail.com Brother Crete Saline Nebraska Bryan Linares Chris Linares Signed
1034 2022-04-05 11:43 Anonymous (not verified) 75.162.133.214 Riftworks Wood Manufactory Proprietorship 3807 Adams Ave, Des moines, Iowa 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-05 Bryan Siever bryan@siever.us Des Moines IA United States Cakeb Payne Tyler Anderson Signed (1) The employer does not elect the employers’ liability coverage. Bryan siever bryan@siever.us Business owner Des Moines IA United States Caleb Payne Tyler Anderson Signed
1662 2023-05-25 12:52 Anonymous (not verified) 94.188.205.176 Affordable Painting and Renovations of Iowa LLC Limited Liability Company 1418 NW Applewood 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. 2023-05-25 Bryan Thieleke affordablerenoiowa@yahoo.com Ankeny Polk Iowa Mike Kaut Adam Lozano Signed (1) The employer does not elect the employers’ liability coverage. Bryan Thieleke affordablerenoiowa@yahoo.com Owner Ankeny Polk Iowa Mike kaut Adam lozano Signed
1663 2023-05-25 12:56 Anonymous (not verified) 94.188.205.167 Affordable Painting and Renovations of Iowa LLC Limited Liability Company 1417 NW Applewood 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. 2023-05-25 Bryan Thieleke affordablerenoiowa@yahoo.com Ankeny Polk Iowa Mike kaut Adam lozano Signed (1) The employer does not elect the employers’ liability coverage. Bryan Thieleke affordablerenoiowa@yahoo.com Owner Ankeny Polk Iowa Mike kaut Adam lozano Signed
2034 2024-02-07 11:58 Anonymous (not verified) 94.188.207.230 Bryce Abbott Proprietorship 114 West Linn Street, Lone Tree, IA 52755 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-31 Bryce David Abbott bryceabbott86@gmail.com Lone Tree Johnson United States Dixie Abbott Andy Abbott Signed (1) The employer does not elect the employers’ liability coverage. Bryce Abbott bryceabbott86@gmail.com Self Lonetree Johnson IA Dixie Abbott Andy Abbott Signed
1410 2023-01-06 10:58 Anonymous (not verified) 173.25.103.95 Bryce Kenworthy Proprietorship 155 NW Maple St 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. 2023-01-06 Bryce Kenworthy midwest.fencingandconstruction@gmail.com Elkhart Polk Iowa Kevin Corn Nicole Almburg Signed (1) The employer does not elect the employers’ liability coverage. Bryce Kenworthy midwest.fencingandconstruction@gmail.com Owner Elkhart Polk Iowa Kevin Corn Nicole Almburg Signed
2134 2024-04-04 08:10 Anonymous (not verified) 94.188.205.169 TERRA CONSTRUCTION LLC Limited Liability Company 621 Oak Park Ave Des Moines, IA 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2024-04-04 Bryce Shabazz block.radio@yahoo.com Des Moines Polk Iowa Megan Donigan George Hana Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jessica L Heller Jessica.heller@adp.com Insurance Agent Allentown Lehigh PA Megan Donigan George Hana Signed
935 2022-02-24 09:44 Anonymous (not verified) 174.215.244.252 Cornejo Construction Limited Liability Company 419 2nd 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. 2022-02-24 Bulmaro Cornejo cruzcornejo4314@gmail.com Perry Dallas Iowa Jose Cruz Cornejo Andrade Brenda Espinoza Signed (1) The employer does not elect the employers’ liability coverage. Bulmaro Cornejo cruzcornejo4314@gmail.com Owner Perry Dallas Iowa Jose Cruz Cornejo Brenda Espinoza Signed
2102 2024-03-18 10:56 Anonymous (not verified) 94.188.207.228 NBJ Construction LLC Limited Liability Company 2536 Capitol Ave Des Moines IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-18 Byron Jose Hernandez Nunez bjhernandez198807@gmail.com Des Moines Polk Iowa Nathan Miller Greg Beck Signed (1) The employer does not elect the employers’ liability coverage. NBJ Construction LLC bjhernandez198807@gmail.com Owner Des Moines Polk Iowa Nathan Miller Greg Beck Signed
1009 2022-03-28 07:24 Anonymous (not verified) 173.18.6.21 Clay Windelmann Limited Liability Company 362 Public Square, Greenfield, IA 50849 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-28 C;ay Winkelman crwwproperties@gmail.com Fontanelle Adair Iowa Kathryn Larson Jacob Tiernan Signed (1) The employer does not elect the employers’ liability coverage. Clay Winkelmann crwwproperties@gmail.com Owner/Self Fontanelle Adair Iowa Kathryn Larson Jacob Tiernanq Signed
310 2020-11-09 13:32 Anonymous (not verified) 75.89.78.93 CA Smith LLC Limited Liability Company 805 N Hayes Street Mount Ayr, Iowa 50854 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-01 CA Smith LLC smithoil.cs@gmail.com Mount Ayr Ringgold Iowa Wm H French Deborah Creveling Signed (1) The employer does not elect the employers’ liability coverage. CA Smith LLC smithoil.cs@gmail.com Self Mount Ayr Ringgold Iowa Wm H French Deborah Creveling Signed
2061 2024-02-28 14:16 Anonymous (not verified) 94.188.205.166 Cael Gulrud Proprietorship 206 W Main St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-28 Cael Gulrud gulrud8728@gmail.com Calmar IA United States Belle Olsgard David Gulrud Signed (1) The employer does not elect the employers’ liability coverage. Cael Gulrud gulrud8728@gmail.com Me Calmar IA United States Belle Olsgard David Gulrud Signed
1694 2023-06-16 14:37 Anonymous (not verified) 94.188.205.176 Leaf Home Solutions LLC Partnership 3060 SE Grimes Blvd Suite 100-300, 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. 2023-06-16 Caleb Brincks chbrincks@gmail.com 628 NE 56th St Ankeny IA, 50021 Polk County Iowa Melissa Brincks Anisha Moten Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. AFTON INC chbrincks@gmail.com Owner Ankeny Polk Iowa Melissa Brincks Anisha Moten Signed
10 2019-12-16 11:35 Anonymous (not verified) 50.81.115.85 Travis Garrett and Caleb Elliott Partnership P.O. Box 55, Boone, IA 50036 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-12-16 Caleb Elliott onethird4599@gmail.com Boone Boone IA Katie Frame Jessica Carroll Signed (1) The employer does not elect the employers’ liability coverage. Travis Garrett & Caleb Elliott onethird4599@gmail.com Owner Boone Boone IA Katie Frame Jessica Carroll Signed
1085 2022-05-03 10:38 Anonymous (not verified) 65.144.174.26 Caleb Schroeder Proprietorship 4051 SW 56th St Des Moines, IA 50321 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-03 Caleb Schroeder calebpschroeder@gmail.com Des Moines Polk Iowa Michele Schroeder Donald Schroeder Signed (1) The employer does not elect the employers’ liability coverage. Caleb Schroeder calebpschroeder@gmail.com Self Des Moines Polk Iowa Michele Schroeder Donald Schroeder Signed
1191 2022-07-07 12:15 Anonymous (not verified) 207.177.48.254 Day Ag Service LLC Proprietorship 28250 240th Street Dallas Center, IA 50063 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-07 Calvin Brewer Day cal.d.day@gmail.com Dallas Center Dallas IA Dale Day Mary Beth Day Signed (1) The employer does not elect the employers’ liability coverage. Calvin Brewer Day cal.b.day@gmail.com Self Dallas Center Dallas IA Dale Day Mary Beth Day Signed
217 2020-07-27 14:56 Anonymous (not verified) 72.2.163.232 Calvin Kroger Proprietorship 48232 292nd St. Hudson, SD 57034 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-27 Calvin Kroger calvinkroger@gmail.com Hudson Lincoln South Dakota Robin Anderson Adam Anderson Signed (1) The employer does not elect the employers’ liability coverage. Calvin Kroger calvinkroger@gmail.com proprietor Hudson Lincoln South Dakota Robin Anderson Adam Anderson Signed
1023 2022-03-31 10:34 Anonymous (not verified) 173.23.251.188 Thede Home Improvement Proprietorship 1940 86th St Windsor Heights, IA 50324 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-31 Cameron Thede camthede22@gmail.com Windsor Heitghts Polk IA Tara Murphy Mike Ryerson Signed (1) The employer does not elect the employers’ liability coverage. Cameron Thede camthede22@gmail.com owner Windsor Heights Polk IA Tara Murphy Mike Ryerson Signed
186 2020-06-15 08:03 Anonymous (not verified) 66.188.136.150 Candace Dingler Proprietorship 280 Trimble Station Road I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-10 Candace Dingler kschumacher@tricorinsurance.com Hogansville Troup GA Russell Masartis Angie Ords Signed (1) The employer does not elect the employers’ liability coverage. Candace Dingler kschumacher@tricorinsurance.com Same Hogansville Troup GA Russell Masartis Angie Ords Signed
86 2020-03-09 08:19 Anonymous (not verified) 198.167.182.164 Simply Anchored LLC dba Simply Mae's Limited Liability Company 601 Broad St, Story City, IA 50248 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-05 Cande Coulter cande@simplymaes.com Story City Story Iowa Lynn McKinney Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Candy Coulter cande@simplymaes.com Managing Member Story City Story Iowa Lynn McKinney Dyan Kriener Signed
2040 2024-02-08 10:35 Anonymous (not verified) 94.188.207.226 Storm Pro Solution Limited Liability Company 1309 Coffeen Sheridan,wy 82801 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-08 Candis Henderson Cneal@stormprosolution.com Broadview Chicago Illinois Chester Neal Eric Henderson Signed (1) The employer does not elect the employers’ liability coverage. Candis Henderson Cneal@stormprosolution.com Self Broadview Chicago Illinois Chester neal Eric Henderson Signed
316 2020-11-13 11:46 Anonymous (not verified) 66.188.136.150 Canebreak & Warlander Trucking, LLC Limited Liability Company 1020 Avenue F, Fort Madison, IA 52627 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-13 Canebreak & Warlander Trucking LLC kschumacher@tricorinsurance.com Fort Madison Lee IA Russell Masartis Nancy Wortley Signed (1) The employer does not elect the employers’ liability coverage. Canebreak & Warlander Trucking LLC kschumacher@tricorinsurance.com Same Fort Madison Lee IA Russell Masartis Nancy Wortley Signed
852 2022-01-21 15:52 Anonymous (not verified) 75.162.3.62 Alternative Interventions, LLC Limited Liability Company 3116 Ingersoll, #4 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-21 Carla Olson altint3116@gmail.com West Des Moines Dallas United States Michelle Grandstaff Alexandra Killinger Signed (1) The employer does not elect the employers’ liability coverage. CARLA OLSON altint3116@gmail.com Owner DES MOINES Polk United States Michelle Grandstaff Alexandra Killinger Signed
1411 2023-01-06 12:35 Anonymous (not verified) 72.255.93.91 Amayas Painting Proprietorship 1501 Mattern Ave, Des Moines, IA 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-01 Carlos Alexando Amaya Garcia bmoellers@thebookkeepersinc.net Des moines Polk IA Tammy Robbins Gary Cort Signed (1) The employer does not elect the employers’ liability coverage. Brett Moelles bmoellers@thebookkeepersinc.net Accountant Des Moines Polk IA Tammy Robbins Gary Cort 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
1439 2023-02-06 11:00 Anonymous (not verified) 96.31.1.206 L&C LLC Limited Liability Company 615 W 6TH ST ESTHERVILLE, IA 51334 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-06 CARLOS MEDINA joel@walkerinsuranceia.com Estherville EMMET IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. CARLOS MEDINA joel@walkerinsuranceia.com SELF Estherville EMMET IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1705 2023-06-23 16:01 Anonymous (not verified) 94.188.205.176 MV Carpentry LLC Limited Liability Partnership 32724 U.S. 69 Huxley IA 50124 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-23 Carlos Moreno Silencitopunk@gmail.com Huxley IA United States Alejandro Colin Fermin Luz Signed (1) The employer does not elect the employers’ liability coverage. Carlos Moreno silencitopunk@gmail.com Husband Huxley IA United States Alejandro Colin Fermin Luz Signed
958 2022-03-08 20:17 Anonymous (not verified) 50.82.39.158 Ramos Drywall Limited Liability Company 1355 Ozark Ridge, Coralville, IA 52241 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-03-08 Carlos Rene Ramos Martinez carlosramos2345@gmail.com Coralville Iowa United States Breanna Barragan Eliseo Tapia JR. Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Carlos Rene Ramos Martinez carlosramos2345@gmail.com N/A- Same Person Coralville Johnson County IA Breanna Barragan Eliseo Tapia JR. Signed
872 2022-01-30 18:54 Anonymous (not verified) 75.162.11.91 Iowa Carpentry Construction Limited Liability Company 3000 University Ave #18105 West Des Moines,IA 50266 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-30 Carlos Velazquez jlctrimcarpenter@gmail.com Wes Des Moines Polk Iowa Carlos Velazquez Martha Marca Signed (1) The employer does not elect the employers’ liability coverage. Iowa Carpentry Construcion iowacarpentryconstruction@gmail.com Worker West Des Moines Polk Iowa Carlos Velazquez Martha Marca Signed
1637 2023-05-10 15:39 Anonymous (not verified) 94.188.207.230 Carly Roskop Proprietorship 7706 Hampshire Ct 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. 2023-05-10 Carly Roskop carlyroskop@gmail.com Cedar Rapids IA United States Dustin Roskop Tracy Petrak Signed (1) The employer does not elect the employers’ liability coverage. Carly Roskop carlyroskop@gmail.com Self Cedar Rapids IA United States Dustin Roskop Tracy Petrak Signed
1614 2023-04-27 15:18 Anonymous (not verified) 94.188.205.177 Crawford Construction Services LLC Limited Liability Company 1018 Creston Ave, Des Moines, Ia 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-27 Casey D Crawford crawfordcasey8824@gmail.com Des Moines Polk Iowa Nicole Powell Steve Crawford Signed (1) The employer does not elect the employers’ liability coverage. Casey D Crawford crawfordcasey8824@gmail.com Owner Des Moines Polk Iowa Nicole Powell Steve Crawford Signed
327 2020-11-25 10:38 Anonymous (not verified) 173.31.147.225 CASEY KYLE Proprietorship 1505 9TH ST MILFORD IA 51351 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-12-01 CASEY KYLE JOEL@WALKERINSURANCEIA.COM MILFORD DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The employer does not elect the employers’ liability coverage. CASEY KYLE JOEL@WALKERINSURANCEIA.COM SELF MILFORD DISCKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
2017 2024-02-01 15:23 Anonymous (not verified) 94.188.205.174 SolQ, LLC Limited Liability Company 184 N 100 E Suite A Logan UT 84321 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-01 Casey Ryan Winger casey@solq.com Providence Cache UT Perry M. Koger Rebecca Koger Signed (1) The employer does not elect the employers’ liability coverage. Casey Ryan Winger casey@solq.com Owner Providence Cache Utah Perry M. Koger Rebecca Koger Signed
537 2021-06-07 15:25 Anonymous (not verified) 66.188.136.150 Casey Young Proprietorship 10731 State Highway 118 Turrell, AR 72384 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-03 Casey Young kschumacher@tricorinsurance.com Turrell Crittenden AR Mitch Kemp Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Casey Young kschumacher@tricorinsurance.com Same Turrell Crittenden AR Mitch Kemp Shuree Behr Signed
1093 2022-05-12 06:32 Anonymous (not verified) 50.80.25.116 Beast Construction LLC Limited Liability Company 1025 O Ave NW, Cedar Rapids, IA 52405 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-01 Catarino Martinez Alvarez - H&C Roofing LLC handc.rconst@outlook.com North Liberty Johnson Iowa Evelyn Lagos Edgardo Hernandez Signed (1) The employer does not elect the employers’ liability coverage. Greg Saunders Gsaunders@beastconstructioncr.com Owner Cedar Rapids Linn Iowa Laura Sturm Joanie Lacayo Signed
1536 2023-03-27 10:47 Anonymous (not verified) 94.188.205.174 Cecile C Knipp Limited Liability Company 1418 Oakcrest Dr., Waterloo, IA 50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-27 Cecile C Knipp ceilknipp@gmail.com Waterloo Black Hawk Iowa Monica Robbins Anne Betts Signed (1) The employer does not elect the employers’ liability coverage. Cecile C Knipp christinaknipp@aol.com Self Waterloo Black Hawk Iowa Monica Robbins Anne Betts Signed
348 2020-12-31 14:09 Anonymous (not verified) 66.129.217.166 Premier Plus LLC Limited Liability Company 1930 St Andrews Crt NE, Suite A, Cedar Rapids, IA 52402 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-12-01 Cerby Newton tonypauljohnson@yahoo.com Cedar Rapids IA United States Olvin Lanza Anthony Johnson Signed (1) The employer does not elect the employers’ liability coverage. Cerby Newton tonypauljohnson@yahoo.com Owner Cedar Rapids IA United States Anthony Johnson Olvin Lanza Signed
1656 2023-05-22 11:48 Anonymous (not verified) 94.188.205.169 Cesar Arroyo Proprietorship 2207 Lisa Drive, Webster City IA 50595 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-18 Cesar Arroyo office.seamlesspros@icloud.com Webster City Hamilton Iowa Jessica Knutson Keith Clabaugh Signed (1) The employer does not elect the employers’ liability coverage. Cesar Arroyo office.seamlesspros@icloud.com Self Webster City Hamilton Iowa Jessica Knutson Keith Clabaugh 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
1793 2023-08-09 15:23 Anonymous (not verified) 94.188.205.174 Cesar estuardo marroquin gonzalez Proprietorship 1212 David st waterloo iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-09 Cesar estuardo marroquin gonzalez marroquincesar1788@gmail.com 1212 David st waterloo iowa Black haw Iowa Sonia Gomez Sonia Gomez Signed (1) The employer does not elect the employers’ liability coverage. Cesar estuardo marroquin gonzalez marroquincesar1788@gmail.com Patrón 1212 David st waterloo iowa Black hawn Iowa Sonia Gomez Sonia Gomez Signed
1252 2022-08-12 13:11 Anonymous (not verified) 166.181.85.235 Cesar cardenas Proprietorship 48644 roma valley dr I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-06 Cesar Octavio Cardenas navarrete cesarcardenas981@gmail.com Des moines Polk Iowa Cesar cardenas navarrete Cesar cardenas Gonzalez Signed (1) The employer does not elect the employers’ liability coverage. Cesar cardenas cesarcardenas981@gmail.com Myself Des moines Polk Iowa Cesar cardenas Cesar cardenas gonzalez Signed
916 2022-02-16 09:23 Anonymous (not verified) 173.18.22.217 Cesar Ponce Proprietorship 150 Aspen Dr. Norwalk IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-16 Cesar Ponce cesarponce00@icloud.com Nowalk Warren Iowa Lesa Reeves Jennifer Lambert Signed (1) The employer does not elect the employers’ liability coverage. Cesar Ponce cesarponce00@icloud.com Owner Norwalk Warren Iowa Lesa Reeves Jennifer Lambert Signed
1200 2022-07-11 19:24 Anonymous (not verified) 208.126.69.118 CMG Safety Limited Liability Company 325 1st st. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-11 Chace Michael Garner chgarner18@gmail.com Truro Madison Iowa Josh Tomkins Kirsten Schirm Signed (1) The employer does not elect the employers’ liability coverage. Josh Tompkins josh.thomkins@307safety.com Contractor Gillette Cambell Wyoming Chace Garner Kirsten Schirm Signed
288 2020-10-21 18:36 Anonymous (not verified) 173.218.73.44 Bilyeu Underground LLC Limited Liability Company 1136 W. Irene Ct. Nixa, MO 65714 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-21 Chad Anthony Charles y4ardgn0m3r@gmail.com Nixa Christian Missouri Gary George Bilyeu Daniel Bilyeu Signed (1) The employer does not elect the employers’ liability coverage. Chad Anthony Charles y4ardgn0m3r@gmail.com Owner Nixa Christian Missouri Gary George Bilyeu Daniel Bilyeu Signed
283 2020-10-21 09:19 Anonymous (not verified) 192.16.108.199 Blazin Homes Proprietorship 2306 Hill St Denison Iowa 51442 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-21 Chad David Blasey chadblasey@yahoo.com Denison Crawford Iowa Amy Hansen Todd Stadtlander Signed (1) The employer does not elect the employers’ liability coverage. Chad David Blasey chadblasey@yahoo.com Owner Dension Crawford Iowa Amy Hansen Todd Stadtlander Signed
1889 2023-11-01 06:44 Anonymous (not verified) 94.188.207.226 Williams Hardwood Flooring LLC Limited Liability Company P.O. Box 22 Marion, 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. 2023-11-01 Chad Everett William williamshardwoodflooringllc@gmail.com Anamosa Jones IA Tara Williams Sarah Williams Signed (1) The employer does not elect the employers’ liability coverage. Chad E Williams williamsharfwoodflooringllc@gmail.com Me Anamosa Jones IA Tara Williams Sarah Williams Signed
1247 2022-08-08 16:43 Anonymous (not verified) 72.13.27.236 Williams Hardwood Flooring LLC Limited Liability Company 10359 Deer Trail I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-05 Chad Everett Williams williamshardwood@aol.com Anamosa IA IA Shane Kies Dave Reitseger Signed (1) The employer does not elect the employers’ liability coverage. Chad Everett Williams williamshardwood@aol.com Owner Anamosa IA IA Shane Kies Dave Reitseger Signed
173 2020-06-04 11:22 Anonymous (not verified) 167.142.93.121 Chad Hauschild dba Chad Hauschild Logging Proprietorship 23864 190th St, Farmersburg, IA 52047 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-04 Chad Hauschild michael@giffordinsurance.net Farmersburg Clayton Iowa Angela Keppler Kevin Lau Signed (1) The employer does not elect the employers’ liability coverage. Chad Hauschild michael@giffordinsurance.net Self Farmersburg Clayton Iowa Angela Keppler Kevin Lau Signed
1383 2022-12-07 14:42 Anonymous (not verified) 96.31.1.206 IGL RENTAL LLC Limited Liability Company PO BOX 317 ARNOLDS PARK IA 51331 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-25 CHAD JONES STAYBOJI@GMAIL.COM ARNOLDS PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. CHAD JONES STAYBOJI@GMAIL.COM SELF ARNOLDS PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
231 2020-08-13 18:22 Anonymous (not verified) 173.27.28.18 Kelley Contracting Proprietorship 115 Pinecrest Circle Elk Run Heights, Ia 50707 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-13 Chad Kelley chadkelley22@gmail.com Elk Run Heights Black Hawk Iowa Jack Kelley Jennifer Kelley Signed (1) The employer does not elect the employers’ liability coverage. Kelley Contracting chadkelley22@gmail.com Self Elk Run Heights Black Hawk Iowa Jack Kelley Jennifer Kelley Signed
151 2020-05-07 15:57 Anonymous (not verified) 198.167.182.164 Hawk-I Trucking LLC Limited Liability Company 521 Greenfield Dr, Tiffin, IA 52340 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-06 Chad Lee Freeman ricenogle@southslope.net Tiffin Johnson IA Scott Freeman Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Chad Lee Freeman ricenogle@southslope.net Managing Member Tiffin Johnson IA Scott Freeman Dyan Kriener Signed
2116 2024-03-27 09:53 Anonymous (not verified) 94.188.205.175 Purdy Pretty Projects inc Proprietorship 5380 13 ave, La porte city, IA 50651, US I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Chad Purdy redtactor12345@gmail.com La porte city LaPorte County Iowa Jordan Nisiewicz Jordan Loyd Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Johnson Missouri Jordan Loyd Warren Crow Signed
2020 2024-02-02 07:14 Anonymous (not verified) 94.188.207.230 SM4 Consulting LLC Limited Liability Company 503 E 6TH ST I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-02 Chad Smith sm4consultingllc@gmail.com PRAIRIE CITY Jasper Iowa Nicole Smith Maybelle Smith Signed (1) The employer does not elect the employers’ liability coverage. Chad Smith sm4consultingllc@gmail.com self PRAIRIE CITY Jasper Iowa Nicole Smith Maybelle Smith Signed
1457 2023-02-15 18:06 Anonymous (not verified) 94.188.205.166 Chad Cowan Limited Liability Company 2108 Locust St West Des Moines IA 50265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-15 Chad Stuart Cowan chad@bigroofing515.com West Des Moines Polk Iowa Paul Mouw Rob Schultz Signed (1) The employer does not elect the employers’ liability coverage. Chad Cowan rr2cw@yahoo.com Same West Des Moines IA United States Paul Mouw Rob Schultz Signed
208 2020-07-16 20:24 Anonymous (not verified) 216.127.193.93 Sequoia Integrative Medical Services Limited Liability Company W2560 Birschbach Drive, Mount Calvary, WI, 53057 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-16 Chad Weston Gardner chadwestongardner@yahoo.com Mount Calvary Fond du Lac Wisconsin Emily Lucht Ron Carpenter Signed (1) The employer does not elect the employers’ liability coverage. Chad Weston Gardner chadwestongardner@yahoo.com Self Mount Calvary Fond du Lac Wisconsin Emily Lucht Ron Carpenter Signed
624 2021-08-30 15:53 Anonymous (not verified) 174.253.66.113 Leaf Home Solutions LLC Limited Liability Company 1595 Georgetown 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. 2021-08-30 Chad York Cyork027@gmail.com Davenport Scott Iowa Chad York Adam Coleman Signed (1) The employer does not elect the employers’ liability coverage. Adam Coleman ARColeman@leafhome.com Recruiter Hudson Summit Ohio Chad York Adam Coleman Signed
749 2021-11-15 16:05 Anonymous (not verified) 173.31.148.43 CHAMONE SWITZER Proprietorship PO BOX 72 FOSTORIA IA 51340 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-15 CHAMONE SWITZER CHAMONE.SWITZER@GMAIL.COM FOSTORIA DICKINSON IOWA TAMI KLEIN JENNIFER YOUNG WIRTH Signed (1) The employer does not elect the employers’ liability coverage. CHAMONE SWITZER CHAMONE.SWITZER@GMAIL.COM SELF FOSTORIA IA United States TAMI KILEIN JENNIFER YOUNGWIRTH Signed
696 2021-10-28 10:33 Anonymous (not verified) 173.18.85.215 Saunders Construction Proprietorship 7304 SW 14th St Des Moines Iowa 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-28 Charles A Saunders charlessaunders901@gmail.com Des Moines IA United States Ramona Mitchell Rasheedah Gasaway Signed (1) The employer does not elect the employers’ liability coverage. Charles Saunders charlessaunders901@gmail.com Owner Des Moines Polk Iowa Ramona Mitchell Rasheedah Gasaway Signed
811 2021-12-22 17:31 Anonymous (not verified) 166.181.85.89 Demmer Construction Proprietorship 203 Michigan Ave Farley, IA 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. 2021-12-22 Charles Demmer charliedemmer@gmail.com Farley Dubuque Ia Michele Demmer Jennifer White Signed (1) The employer does not elect the employers’ liability coverage. Charles Demmer charliedemmer@gmail.com Self Farley Dubuque Ia Michele Kay Demmer Jennifer Marie White Signed
812 2021-12-22 17:31 Anonymous (not verified) 166.181.85.89 Demmer Construction Proprietorship 203 Michigan Ave Farley, IA 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. 2021-12-22 Charles Demmer charliedemmer@gmail.com Farley Dubuque Ia Michele Demmer Jennifer White Signed (1) The employer does not elect the employers’ liability coverage. Charles Demmer charliedemmer@gmail.com Self Farley Dubuque Ia Michele Kay Demmer Jennifer Marie White Signed
1012 2022-03-28 14:42 Anonymous (not verified) 97.125.50.9 Charles Grimes Proprietorship 1041 NW Victoria Ln, Waukee, IA 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-28 Charles Grimes maurcedes98@gmail.com Waukee Dallas Iowa Dave Tomlin Lavon Grimes Signed (1) The employer does not elect the employers’ liability coverage. Charles Grimes maurcedes98@gmail.com self Waukee Dallas IA Dave Tomlin Lavon Grimes Signed
1715 2023-06-28 09:48 Anonymous (not verified) 94.188.207.229 Charles westbrook Limited Liability Company 2374 31st a Moline I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2023-06-28 Charles Micheal westbrook Westbrook.69.mw@gmail.com Moline USA Illinois Taylor Davis N/a Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Charles Micheal Westbrook Westbrook.69.mw@gmail.com Gf Moline IL United States Taylor davis N/a Signed
482 2021-04-14 21:21 Anonymous (not verified) 98.17.35.5 K3 Recycling LLC Limited Liability Company 14801 180th Ave, Milo, IA 50166 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-14 Charles Raymond Kappelman charliekappelman@yahoo.com MILO Warren United States Ryan Matthew Kappelman John Allen Bahr Signed (1) The employer does not elect the employers’ liability coverage. K3 Recycling LLC charliekappelman@yahoo.com Co-owner Milo Warren Iowa Ryan Matthew Kappelman John Allen Bahr Signed
701 2021-10-29 18:35 Anonymous (not verified) 173.18.85.215 Saunders Construction Proprietorship 7304 SW 14th 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. 2021-10-29 Charles Saunders charlessaunders901@gmail.com Des Moines Iowa Iowa Ramona Mitchell Rasheedah Gasaway Signed (1) The employer does not elect the employers’ liability coverage. Charles Saunders charlessaunders901@gmail.com Owner Des Moines IA United States Ramona Mitchell Rasheedah Gasaway Signed
1861 2023-10-05 10:14 Anonymous (not verified) 94.188.207.227 Charles von Maur Proprietorship 18325 Robbins Road Pleasant Valley IA 52767 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-05 Charles von Maur rlarsen@vonmaur.com Pleasant Valley Scott IA Robert L Larsen Amanda Bratthauer Signed (1) The employer does not elect the employers’ liability coverage. Robert L Larsen rlarsen@vonmaur.com Outside consultant east moline Rock Island IL Josh Barnes Amanda Bratthauer Signed
1956 2023-12-14 13:45 Anonymous (not verified) 94.188.207.226 Fey Concrete Inc Proprietorship 307 East Judson St, Maquoketa, IA 52060 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-14 Charles W Fey chuckfey55@gmail.com Maquoketa Jackson Iowa Susan Croatt Dave Stockham Signed (1) The employer does not elect the employers’ liability coverage. Charles W Fey chuckfey55@gmail.com Owner/same Maquoketa Jackson Iowa Susan Croatt Dave Stockham Signed
1761 2023-07-26 08:40 Anonymous (not verified) 94.188.207.224 Gerk Trucking Proprietorship 401 W college, Stacyville, IA 50476 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-26 Charles W. Gerk cwgerk@gmail.com Stacyville Mitchell iowa Jeannie Lemke Robin Tabbert Signed (1) The employer does not elect the employers’ liability coverage. Charles W. Gerk cwgerk@gmail.com Same Stacyville Mitchell Iowa Jeannie Lemke Robin Tabbert Signed
334 2020-12-07 12:38 Anonymous (not verified) 173.19.190.160 Broadband Installations of Iowa LLC Limited Liability Company P.O. Box 728 Carroll, IA 51401 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-12-07 Charles Wood cwood.bband@outlook.com CEDAR RAPIDS IA IA Eva Wood Tamara Wood Signed (1) The employer does not elect the employers’ liability coverage. Skyla Siech skylabbi@outlook.com Offcie Manager Ely Linn Iowa Melvin Harter Eddie Bell Signed
414 2021-02-28 15:32 Anonymous (not verified) 174.198.75.211 Charlie Christian Hutt Proprietorship 609 E. main 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. 2021-01-29 Charlie Christian Hutt bmxican_04@hotmail.com Brooklyn poweshiek IA gene shafbough hannah hutt Signed (1) The employer does not elect the employers’ liability coverage. Charlie Christian Hutt bmxican_04@hotmail.com sole Brooklyn poweshiek IA gene shafbough hannah hutt Signed
1314 2022-09-19 16:43 Anonymous (not verified) 96.31.1.206 CHARVEL TREJO Proprietorship 1113 L AVE, MILFORD, IA 51331 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-19 CHARVEL TREJO LEVRACH@YAHOO.COM MILFORD DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The employer does not elect the employers’ liability coverage. CHARVEL TREJO LEVRACH@YAHOO.COM SELF MILFORD DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
1892 2023-11-02 12:24 Anonymous (not verified) 94.188.205.169 TREJO'S CONSTRUCTION LLC Limited Liability Company 1113 L AVE, MILFORD, IA 51351 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-02 CHARVEL TREJO levrach@yahoo.com MILFORD DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The employer does not elect the employers’ liability coverage. CHARVEL TREJO levrach@yahoo.com SELF MILFORD DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
1423 2023-01-16 14:03 Anonymous (not verified) 173.224.19.200 Hoofin-It Proprietorship 86148 537th Ave. Plainview, NE 68769 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-16 Chase Terrill terrill365@gmail.com Pierce Pierce Nebraska Jim Aschoff Calan List Signed (1) The employer does not elect the employers’ liability coverage. Cole Aschoff aschoff_2@icloud.com Co-Owner Plainview Pierce Nebraska Jim Aschoff Calan List Signed
2165 2024-04-19 14:05 Anonymous (not verified) 94.188.207.225 Apex Striping LLC Limited Liability Company 1325 Western Ave, cedar Falls, IA. 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-19 Chaz Ernest Torres admin@apexstripingia.com Cedar Falls Blackhawk Iowa Theresa Jo Torres Eloy James Torres Signed (1) The employer does not elect the employers’ liability coverage. Chaz Ernest Torres admin@apexstripingia.com Self Cedar Falls Blackhawk Iowa Theresa Jo Torres Eloy James Torres Signed
925 2022-02-17 13:07 Anonymous (not verified) 208.81.192.69 Wapsie Valley Construction, LLC Limited Liability Company 1154 Dennison Ave., Fairbank, IA 50629 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-17 Chester H. Borntrager accounting@robertseddy.com Hazleton Buchanan Iowa Brian C. Eddy Samantha J. Stelter Signed (1) The employer does not elect the employers’ liability coverage. Merle Miller accounting@robertseddy.com Same person Fairbank Buchanan Iowa Brian C. Eddy Samantha J. Stelter Signed
1652 2023-05-17 20:44 Anonymous (not verified) 94.188.205.167 Fox Trucking Proprietorship 2774 March Ave Greene Ia. 50636 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-17 Chet D. Fox cjakfox@yahoo.com Greene Floyd Iowa Jack Dwyer Chad Olson Signed (1) The employer does not elect the employers’ liability coverage. Chet Fox cjakfox@yahoo.com myself Greene Floyd Iowa Jack Dwyer Chad Olson Signed
32 2020-01-08 08:31 Anonymous (not verified) 199.120.118.90 BOBCATS LLC Limited Liability Company 1860 505TH ST LINN GROVE IOWA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-11-18 CHRIS AXDAHL CHRISAXDAHLINC@HOTMAIL.COM LINN GROVE CLAY IOWA TESSA L STEFFEN JOSEPH E ZENKOVICH Signed (1) The employer does not elect the employers’ liability coverage. CHRIS AXDAHL CHRISAXDAHLINC@HOTMAIL.COM OWNER LINN GROVE CLAY IOWA TESSA L STEFFEN JOSEPH E ZENKOVICH Signed
848 2022-01-20 13:56 Anonymous (not verified) 50.82.130.211 Albatross Capital, LLC Limited Liability Company 28003 290th St., Parkersburg IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-22 Chris Buseman cmins_re@mchsi.com Parkersburg Butler IA Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Chris Buseman cmins_re@mchsi.com Member of LLC Parkersburg Butler IA Chad Campbell Roxanne Kolder Signed
203 2020-07-15 09:39 Anonymous (not verified) 166.181.66.222 High Caliber Fiber Limited Liability Company 2958 110th ave masonville IA, 50654 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-15 Chris cooper chris_cooper@highcaliberfiber.com Masonville Delaware Iowa Nick beranek Nicole kintzle Signed (1) The employer does not elect the employers’ liability coverage. Chris Cooper chris_cooper@highcaliberfiber.com N/A Masonville Delaware Iowa Nick beranek Nicole kintzle Signed
1160 2022-06-20 10:08 Anonymous (not verified) 138.43.237.249 High Caliber Fiber Limited Liability Company 2958 110th ave masonville IA, 50654 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-20 chris cooper Chris_cooper@highcaliberfiber.com Masonville Delaware IA Laura Rose Lentz Blake Dean Elbert Signed (1) The employer does not elect the employers’ liability coverage. Chris Cooper Chris_cooper@highcaliberfiber.com self Masonville Delaware IA Laura Rose Lentz BLake Dean Elbert Signed
1126 2022-05-25 12:06 Anonymous (not verified) 63.229.189.35 Frame 2 Finish LLC Limited Liability Company 25620 164th St Spirit lake, IA51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-05 Chris Miller frame2finish3550@gmail.com Spirit Lake Dickinson Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Chris Miller frame2finish3550@gmail.com Self SPIRIT LAKE Dickinson Iowa Abigail Miles Alex Miles Signed
1816 2023-08-23 14:59 Anonymous (not verified) 94.188.207.227 CHRIS PIERCE CONSTRUCTION LLC Proprietorship 500 N 8th StAkron, IA 5100 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-23 Chris Pierce chrispierceconstructionllc@gmail.com Akron Plymouth IA Susan Geist Paychex Insurance Agency Signed (1) The employer does not elect the employers’ liability coverage. Susan Geist sgeist@paychex.com Insurance Agency Rochester Monroe NY Susan Geist Paychex Insurance Agency Signed
910 2022-02-10 15:46 Anonymous (not verified) 184.100.98.101 Carich properties Proprietorship 6842 Fawn 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. 2022-02-10 Chris Richard ticketbarandgrill@gmail.com Platteville Grant Wisconsin Allison Richard Melodee Richard Signed (1) The employer does not elect the employers’ liability coverage. Chris Richard ticketbarandgrill@gmail.com Owner Platteville Grant Wisconsin Allison Richard Melodee Richard Signed
2079 2024-03-06 18:59 Anonymous (not verified) 94.188.205.166 Maple Leaf Landscape Maintenance Proprietorship 309 E. Exchange St Geneseo IL 61254 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-05 Chris Walters Mapleleaf@mapleleaflawnsolutions.com GENESEO IL United States Bobbi Jo Cox Victor Snook Signed (1) The employer does not elect the employers’ liability coverage. Chris Walters mapleleaf@mapleleaflawnsolutions.com Self GENESEO IL United States Bobbi Jo Cox Victor Snook Signed
990 2022-03-21 15:18 Anonymous (not verified) 174.192.80.32 Chris Binns Proprietorship 1324 Grand Ave 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. 2022-03-21 Christ Binns christophersbinns@gmail.com Davenpory Scott IA Adam Coleman Rose Snyder Signed (1) The employer does not elect the employers’ liability coverage. Chris Binns christophersbinns@gmail.com Same Davenport Scott IA Adam Coleman Rose Snyder Signed
789 2021-12-14 09:39 Anonymous (not verified) 162.250.36.34 Sylvester Enterprises, LLC Limited Liability Company 4800 Sylvester Rd. Webb, Iowa 51366 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-14 Christian Grant Sylvester slyfarms97@gmail.com Webb Clay iowa Dennis Dwain Somers LInda Elayne Somers Signed (1) The employer does not elect the employers’ liability coverage. Tim Christian Sylvester slyenterprisesllc20@gmail.com Owner Webb Clay Iowa Dennis Dwain Somers Linda Elayne Somers Signed
1323 2022-09-28 22:45 Anonymous (not verified) 74.51.212.66 OUTDOOR MODERN CONCEPTS LLC Limited Liability Company 2520 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. 2022-09-28 CHRISTIAN RUBIO RUBIOCH39@GMAIL.COM DES MOINES POLK IOWA AMANDA DUPRE DARCI CLARK Signed (1) The employer does not elect the employers’ liability coverage. JENNIFER B. CHAVEZ-RIVERA JENNIFER.CHAVEZ-RIVERA@BROWNWINICK.COM ATTORNEY DES MOINES POLK IOWA AMANDA DUPRE DARCI CLARK Signed
1103 2022-05-15 09:56 Anonymous (not verified) 66.6.4.185 Christianson Trucking Inc., Owner Operator Proprietorship 2134 Lakeview Lane Gary SD 57237 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-08 Christianson Trucking Inc., Paul Christianson Owner paulyc63@outlook.com Gary Deuel South Dakota Paul Christianson Nancy Christianson Signed (1) The employer does not elect the employers’ liability coverage. Christianson Trucking Inc., Paul Christianson Owner paulyc63@outlook.com Self Gary Deuel South Dakota Paul Christianson Nancy Christianson Signed
1716 2023-06-29 09:19 Anonymous (not verified) 94.188.205.169 Christine wanjiru chege Limited Liability Company 43994 w cowpath rd I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-29 Christine Chege christine@acuitystaffingagency.com Maricopa Pinal AZ Daniel Mwangi Anne Chege Signed (1) The employer does not elect the employers’ liability coverage. Christine chege christine@acuitystaffingagency.com Owner Maricopa Pinal AZ Daniel Mwangi Anne Chege Signed
1511 2023-03-09 15:52 Anonymous (not verified) 94.188.205.177 CG Welding Limited Liability Company 5400 147th I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-09 Christopher A Lendt weldingiowa@gmail.com Urandale Dallas IA Chris Lendt Chris Lendt Signed (1) The employer does not elect the employers’ liability coverage. Christopher A Lendt weldingiowa@gmail.com Owner Urandale Dallas IA Christopher Lendt Christopher Lendt Signed
1635 2023-05-10 07:25 Anonymous (not verified) 94.188.205.166 Chris Hay Proprietorship 4911 Sutliff Rd Solon, IA 52333 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-10 Christopher A Hay hay2u2@windstream.net Solon Johnson Iowa Brad Bower Kirk Strunk Signed (1) The employer does not elect the employers’ liability coverage. Christopher Hay hay2u2@windstream.net Self Solon Johnson Iowa Brad Bower Kirk Strunk Signed
992 2022-03-21 19:42 Anonymous (not verified) 174.192.66.11 Christopher Binns Proprietorship 1324 Grand Ave, 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. 2022-03-21 Christopher Binns christophersbinns@gmail.com Davenport Scott IA Adam Coleman Rose Snyder Signed (1) The employer does not elect the employers’ liability coverage. Christopher Binns christophersbinns@gmail.com same Davenport Scott IA Adam Coleman Rose Snyder Signed
1377 2022-11-21 13:06 Anonymous (not verified) 166.181.84.102 Leaf home solutions Proprietorship 1595 George Town road 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. 2022-11-21 Christopher da von carpenter chris.carpenter9595@icloud.com Pleasant hill Polk Iowa Clara Francis carpenter Thrinadh gutta Signed (1) The employer does not elect the employers’ liability coverage. Christopher da von carpenter chris.carpenter9595@icloud.com Self Pleasant hill Polk Iowa Clara Francis carpenter Thrinadh gutta Signed
1318 2022-09-22 11:18 Anonymous (not verified) 50.82.91.213 J. Thompson Builders, LLC Limited Liability Company 5291 Stoney Creek Ct. Johnston, IA 50131 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-22 Christopher Jacob Von Arx cjvonarx@hotmail.com Van Wert IA Decatur IA Iowa Christina Viehauser Jeremy Thompson Signed (1) The employer does not elect the employers’ liability coverage. Christina Viehauser christina@jthompsonbuilders.com Office Help Johnston Ia Polk IA Chris Von Arx Jeremy Thompson Signed
518 2021-05-12 19:22 Anonymous (not verified) 184.105.50.148 Angela Smith and Christopher Smith Proprietorship 2321 130th Street Belmond, IA 50421 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-08 Christopher Lynn Smith 1angismith@gmail.com Belmond Wright Iowa Betty Warrington Nicholas Mehmen Signed (1) The employer does not elect the employers’ liability coverage. Angela Kay Smith 1angismith@gmail.com Wife Belmond Wright Iowa Betty Warrington Nicholas Mehmen Signed
1283 2022-08-25 10:23 Anonymous (not verified) 173.29.47.222 Premiere Plastering & Drywall, Inc. Proprietorship 2331 W. 63rd 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. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-08-25 Christopher Payne service@paynedrywall.com Davenport Scott Iowa Jamie Wardlow Kandra Blumenshein Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Premiere Plastering & Drywall, Inc. premiere_pd_llc@yahoo.com Subcontractor Davenport Scott Iowa Jamie Wardlow Kandra Blumenshein Signed
31 2020-01-07 08:37 Anonymous (not verified) 199.10.5.7 Data Information Management LLC Limited Liability Company 703 Bluff St Dubuque IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-07 Christopher R Broessel chris@caricomm.com Dubuque Dubuque IA Janet L Schauff Morris P Schauff Signed (1) The employer does not elect the employers’ liability coverage. Stephen M schauff steve@caricomm.com Partner Dubuque IA Dubuque Iowa Janet L schauff Morris P Schauff Signed
585 2021-07-25 20:07 Anonymous (not verified) 75.162.247.154 CJNR Works, LLC Limited Liability Company 17003 Bowdin Crest Drive, Cypress, Texas 77433 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-25 Christopher Ridgway christopherridgway@gmail.com Cypress Harris TX Sophia Ridgway Mitchel Monahan Signed (1) The employer does not elect the employers’ liability coverage. Christopher Ridgway christopherridgway@gmail.com Self Cypress Harris TX Sophia Ridgway Mitchel Monahan Signed
358 2021-01-12 11:35 Anonymous (not verified) 173.29.116.114 Des Moines Restorations LLC Limited Liability Company 1701 Pennsylvania Avenue, Des Moines, IA 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-12 Christopher Rogers chris@desmoinesrestorations.com Davenport Scott IA Lea Luquire Lisa Rubio Signed (1) The employer does not elect the employers’ liability coverage. Christopher Rogers chris@desmoinesrestorations.com Owner / Employer Davenport Scott IA Lea Luquire Lisa Rubio Signed
359 2021-01-12 11:37 Anonymous (not verified) 173.29.116.114 Quad City Restorations Limited Liability Company 1225 E River Drive, Suite 320, 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. 2021-01-12 Christopher Rogers chris@quadcityrestorations.com DAVENPORT Scott IA Lea Luquire Lisa Rubio Signed (1) The employer does not elect the employers’ liability coverage. Christopher Rogers chris@quadcityrestorations.com Owner / Employer DAVENPORT Scott IA Lea Luquire Lisa Rubio Signed
386 2021-02-08 12:10 Anonymous (not verified) 192.30.185.142 CS Iron Design Proprietorship 311 Powells Addition, Crescent, IA 51526 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-08 Christopher Stoffel ctstoffel@gmail.com Crescent Pottawattamie IA Katie Jenks Nate Blaeser Signed (1) The employer does not elect the employers’ liability coverage. Christopher Stoffel ctstoffel@gmail.com Owner Crescent Pottawattamie IA Katie Jenks Nate Blaeser Signed
1903 2023-11-13 09:08 Anonymous (not verified) 94.188.207.228 Christopher Stone Proprietorship 2427 S Taft Ave Apt #8 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-10 Christopher Stone darrele@ciains.biz Iowa Cerro Gordo IA Chris Fye Darrel Elsbernd Signed (1) The employer does not elect the employers’ liability coverage. Christopher Stone darrele@ciains.biz self Mason City Cerro Gordo Iowa Chris Fye Darrel Elsbernd Signed
1670 2023-05-30 17:07 Anonymous (not verified) 94.188.207.226 Davis&Viteri LLC Limited Liability Company 1125 Florida ave apt 519 Ames Iowa 50014 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-30 Christopher Viteri davisviteri17@gmail.com Johnston Polk Iowa Labron davis Marshalle Coleman Signed (1) The employer does not elect the employers’ liability coverage. Marshalle coleman marshalle.coleman@yahoo.con Friend Ames Story Iowa Marshalle coleman Labron davis Signed
389 2021-02-10 13:59 Anonymous (not verified) 173.24.190.134 Shamrock Lanes, LLC Limited Liability Company 1304 Broadway, PO Box 304, Emmetsburg IA 50536 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-03 Cindy Flannegan cindylou1964@hotmail.com Emmetsburg Palo Alto Iowa Michael Flannegan Laura Sidles Signed (1) The employer does not elect the employers’ liability coverage. Cindy Flannegan cindylou1964@hotmail.com Member of LLC Emmetsburg Palo Alto Iowa Michael Flannegan Laura Sidles Signed
1137 2022-06-01 09:05 Anonymous (not verified) 63.170.122.111 sanchez framing construction llc Limited Liability Company 113 e a st west liberty, ia 52776 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-01 Cindy Sanchez sanchezframingconst.llc@gmail.com west liberty muscatine iowa patricia verdines yajahira estrada Signed (1) The employer does not elect the employers’ liability coverage. n/a sanchezframingconst.llc@gmail.com n/a n/a n/a n/a n/a n/a Signed
16 2019-12-31 08:54 Anonymous (not verified) 70.184.208.208 J & D Transportation Proprietorship 1125 Lew Ross Road Council Bluffs, IA 51501 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-12-31 Clarence Cecil Stogdill jack@jdmmtrucking.com Council Bluffs Iowa United States Mickey Jerome Stogdill Laurie Jo Stogdill Signed (1) The employer does not elect the employers’ liability coverage. Clarence Cecil Stogdill jack@jdmmtrucking.com owner-same person Council Bluffs Iowa United States Mickey Jerome Stogdill Laurie Jo Stogdill Signed
473 2021-04-13 11:26 Anonymous (not verified) 65.103.82.36 Quality Renovation Proprietorship 1406 25th st Moline IL 61265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-06-21 Clarence Marvin Skipton marvinthemartien77@gmail.com Buffalo Scott IA Jennifer Skipton Rose mary Skipton Signed (1) The employer does not elect the employers’ liability coverage. Clarence Marvin Skipton marvinthemartien77@gmail.com Owner Moline Rock Island IL Jennifer skipton rose Skipton Signed
1928 2023-11-29 21:48 Anonymous (not verified) 94.188.205.168 Iowa Evolution Constuction Partnership 1203 Bluegrass Cir I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-01 Claudia Rodriguez claudia.rodriguez.213@gmail.com CEDAR FALLS IA United States Guillermo Nunez Blanca rodriguez Signed (1) The employer does not elect the employers’ liability coverage. Claudia Rodriguez claudia.rodriguez.213@gmail.com Owner CEDAR FALLS IA United States Guillermo Nunez Blanca Rodriguez Signed
1744 2023-07-13 13:52 Anonymous (not verified) 94.188.205.176 T-Rex Construction LLC Limited Liability Company 1203 Bluegrass Circle Unit 4 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. 2023-07-12 Claudia Rodriguez De Nunez t.rexbigbiz@gmail.com CEDAR FALLS IA United States Ana Chavez Alicia Garcia Signed (1) The employer does not elect the employers’ liability coverage. Guillermo Nunez claudia.rodriguez.213@gmail.com Spouse CEDAR FALLS IA United States Alicia Garcia Ana Chavez Signed
1912 2023-11-16 08:40 Anonymous (not verified) 94.188.205.175 JC LANDSCAPING & LAWN CARE Proprietorship 4940 E. SHERIDAN AVE DES MOINES, IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-16 CLAUDIA TORO PINEDA CLAUDIAMEP@HOTMAIL.COM DES MOINES POLK IA BRENDA REEDY ADAM SMITH Signed (1) The employer does not elect the employers’ liability coverage. CLAUDIA TORO PINEDA CLAUDIAMEP@HOTMAIL.COM SELF DES MOINES POLK IA BRENDA REEDY ADAM SMITH Signed
1731 2023-07-10 11:12 Anonymous (not verified) 94.188.207.228 Romer & Associates LLC Limited Liability Company 433 Thomas Avenue, Maquoketa, IA 52060 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-10 Clay K Romer connellsupply@aol.com Maquoketa Jackson IA Susan Croatt Dave Stockham Signed (1) The employer does not elect the employers’ liability coverage. Clay K Romer connellsupply@aol.com Owner/same Maquoketa Jackson IA Susan Croatt Dave Stockham Signed
993 2022-03-22 10:36 Anonymous (not verified) 173.18.6.21 Clay Winkelmann Proprietorship 1652 227th Street, Fontanelle, IA 50846 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-22 Clay Winkelmann crwwproperties@gmail.com Fontanelle Adair Iowa Kathryn Larson Jacob Tiernan Signed (1) The employer does not elect the employers’ liability coverage. Clay Winkelmann crwwproperties@gmail.com Owner Fontanelle Adair Iowa Kathryn Larson Jacob Tiernan Signed
1379 2022-11-22 11:44 Anonymous (not verified) 166.181.89.236 365 Services LLC Limited Liability Company 306 hayes st e hazleton iowa 50641 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-22 Clayton marshall davis Lcrc365@outlook.com Hazleton Bucanan Iowa Grace lilibridge Kurt king Signed (1) The employer does not elect the employers’ liability coverage. Clayton marshall davis Lcrc365@outlook.com Owner Hazleton Bucanan Iowa Kurt kind Grace lilibridge Signed
905 2022-02-08 10:23 Anonymous (not verified) 74.115.101.41 Triple TTT Transport, LLC Limited Liability Company 307 7th Avenue SE, Belmond, IA 50541 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-08 Clint C Christians christiansclint0@gmail.com Pocahontas pocahontas Iowa Dale R Eng Cheri Zimmerman Signed (1) The employer does not elect the employers’ liability coverage. Clint Christians christiansclint0@gmail.com Partner Pocahontas Pocahontas Iowa Dale Eng Cheri Zimmerman Signed
639 2021-09-13 16:10 Anonymous (not verified) 50.81.97.207 Copic Home Maintenance LLC dba Des Moines Drywall Repair Limited Liability Company 1548 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. 2021-09-13 Clint R Copic crcopic@gmail.com Des Moines Polk Iowa Veronica G. Torres Dan Waidelich Signed (1) The employer does not elect the employers’ liability coverage. Clint R Copic dmdrywallrepair@gmail.com self Des Moines Polk Iowa Veronica G Torres Dan Waidelich Signed
83 2020-02-28 12:55 Anonymous (not verified) 204.16.58.27 Baltes Trucking LLC Limited Liability Company 203 N Gilmore Ave New Hampton IA 50659 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-28 Clinton Lee Baltes clintbaltes@gmail.com New Hampton Chickasaw Iowa Tammy Robinson Richard Kramer Signed (1) The employer does not elect the employers’ liability coverage. Clinton Lee Baltes clintbaltes@outlook.com Owner New Hampton Chickasaw Iowa Tammy Robinson Richard Kramer Signed
226 2020-08-07 11:37 Anonymous (not verified) 71.39.227.238 Clinton Luellen Proprietorship 18591 N Ave, Minburn, IA 50167 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-07 Clinton Luellen CALuellen@gmail.com Minburn Dallas Iowa Winette Luellen Don Richardson Signed (1) The employer does not elect the employers’ liability coverage. Clinton Luellen CALuellen@gmail.com Self Minburn Dallas Iowa Winette Luellen Don Richardson Signed
553 2021-07-01 08:17 Anonymous (not verified) 66.188.136.150 Cody Belleville Proprietorship 57167 Copperdate Dr. Elkhart, IN 46516 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-30 Cody Belleville kschumacher@tricorinsurance.com Elkhart Elkhart IN Mitch Kemp Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Cody Belleville kschumacher@tricorinsurance.com Same Elkhart Elkhart IN Mitch Kemp Shuree Behr Signed
329 2020-12-01 10:02 Anonymous (not verified) 74.84.125.43 BRAINARD ROOFING & CONSTRUCTION COMPANY Limited Liability Company 4 South Ross 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. 2020-12-01 Cody Brainard brainardrcc2020@gmail.com Farmersburg Clayton United States Dave Moellers Jordan Cannon Signed (1) The employer does not elect the employers’ liability coverage. Cody Brainard brainardrcc2020@gmail.com I am the authorized agent & employer Farmersburg IA United States Dave Moellers Jordan Cannon Signed
1146 2022-06-07 11:51 Anonymous (not verified) 173.27.226.177 Evans Endeavors LLC Limited Liability Company 513 N Roche 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. 2022-06-07 Cody Evans evansendeavor@gmail.com Knoxville Marion Iowa Erin Six Carl stoffer Signed (1) The employer does not elect the employers’ liability coverage. Cody Evans evansendeavor@gmail.com Myself Knoxville Marion Iowa Erin six Carl Stoffer Signed
49 2020-01-31 12:53 Anonymous (not verified) 74.84.121.206 Cody Kleppe Proprietorship 1891 337th St Decorah IA 52101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-31 Cody Kleppe darrele@ciains.biz Decorah Winneshiek Iowa Chris Fye Darrel Elsbernd Signed (1) The employer does not elect the employers’ liability coverage. Darrel Elsbernd darrele@ciains.biz agent Decorah Winneshiek Iowa Chris Fye Darrel Elsbernd Signed
455 2021-03-31 13:35 Anonymous (not verified) 66.188.136.150 Cody Pazicni Proprietorship 222 Lake Shore Dr. Simpsonville, KY 40067 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-29 Cody Pazicni kschumacher@tricorinsurance.com Simpsonville Shelby KY Russell Masartis Jordan Pape Signed (1) The employer does not elect the employers’ liability coverage. Cody Pazicni kschumacher@tricorinsurance.com Same Simpsonville Shelby KY Russell Masartis Jodan Pape Signed
700 2021-10-29 11:04 Anonymous (not verified) 174.198.66.50 T&C Lawn Care LLC Limited Liability Partnership 1827 Black Hawk St Waterloo IA 50702 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-29 Cody R Woodley cody.woodley50@gmail.com Cedar Falls Blackhawk Iowa Tara R Woodley Sara Woodley Signed (1) The employer does not elect the employers’ liability coverage. Kristi S. Demuth Agency, Inc. kdemuth@amfam.com Client Waverly Bremer Iowa Cody R Woodley Tyler M Croft Signed
901 2022-02-06 16:48 Anonymous (not verified) 50.83.154.236 Cole Jurgle Proprietorship 409 West riverside drive prophetstown IL 61277 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-05 Cole Alexander Jurgle cole.jurgle@gmail.com Prophetstown Whiteside Illinois Nicholas Ray Jurgle Misty Ann Jurgle Signed (1) The employer does not elect the employers’ liability coverage. Cole Alexander Jurgle cole.jurgle@gmail.com self Prophetstown Whiteside Illinois Nicholas Ray Jurgle Misty Ann Jurgle Signed
259 2020-09-16 15:44 Anonymous (not verified) 174.243.82.6 Freedom Maintenance Services LLC Limited Liability Company 1633 2nd St Boone, IA 50036 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-16 Cole Keith McDonald cole.freedomservices@outlook.com Boone Boone IA Troy Thomas Graen Kurtis Joseph Wendl Signed (1) The employer does not elect the employers’ liability coverage. Cole Keith McDonald cole.freedomservices@outlook.com Me Boone Boone IA Troy Thomas Graen Kurtis Joseph Wendl Signed
969 2022-03-11 16:32 Anonymous (not verified) 74.115.101.41 Slaikeu Transport LLC Limited Liability Company 2459 Pine Ave, Humboldt, IA 50548 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-11 Cole Slaikeu cole.slaikeu@gmail.com Humboldt Humboldt IA Dale Eng Troy Rubel Signed (1) The employer does not elect the employers’ liability coverage. Cole Slaikeu cole.slaikeu@gmail.com self Humboldt Humboldt IA Dale Eng Troy Rubel Signed
1831 2023-09-08 11:50 Anonymous (not verified) 94.188.207.223 GFORCE Limited Liability Company 529 Anderson Street Jewell IA 50130 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-06 Colten Abram Griffin G6@q.com Ames Story Iowa Scott Andrew Griffin Hunter Austin Griffin Signed (1) The employer does not elect the employers’ liability coverage. Hunter Austin Griffin G6@q.com Partner Urbandale Polk Iowa Scott Andrew Griffin Colten Abram Griffin Signed
1467 2023-02-17 16:14 Anonymous (not verified) 94.188.205.169 H & C Construction Limited Liability Company 708 Vine Street Lucas IA 50151 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-17 Colton Charles Clarke ccclarke95@gmail.com Truro IA United States Hailey Sullivan Shelby Comer Signed (1) The employer does not elect the employers’ liability coverage. H & C Construction ccclarke95@gmail.com Manager Truro IA United States Hailey Sullivan Shelby Comer Signed
1508 2023-03-09 10:34 Anonymous (not verified) 94.188.205.176 H & C Construction Limited Liability Company 708 Vine Street Lucas IA 50151 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-09 Colton Charles Clarke ccclarke95@gmail.com Truro IA United States Hailey A Sullivan Shelby Comer Signed (1) The employer does not elect the employers’ liability coverage. Colton Charles Clarke ccclarke95@gmail.com Manager Truro IA United States Hailey A Sullivan Shelby Comer Signed
964 2022-03-10 12:41 Anonymous (not verified) 107.115.239.27 KG Land Works LLC Limited Liability Company P.O. Box 931 Barnsdall Ok 74002 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-10 Colton Kelley kglandworks@gmail.com Barnsdall Osage Oklahoma Colton Kelley Dalton Gardner Signed (1) The employer does not elect the employers’ liability coverage. Colton Kelley kglandworks@gmail.com Owner Barnsdall Osage Oklahoma Colton Kelley Dalton Gardner Signed
1879 2023-10-26 13:17 Anonymous (not verified) 94.188.207.224 CR Exteriors Proprietorship 1636 Parktown Ct NE Unit 9 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-26 corey becker cab222.ab@gmail.com cedar rapids linn iowa Brian Ashlock Brian Coover Signed (1) The employer does not elect the employers’ liability coverage. Corey Becker cab222.ab@gmail.com same Cedar Rapids Linn Iowa Brian Ashlock Brian Coover Signed
711 2021-11-04 13:07 Anonymous (not verified) 174.216.69.18 Corey Gramowski Proprietorship 2101 21st ST Emmetsburg IA 50536 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-04 Corey Gramowski gramowski@windstream.net Emmetsburg Palo Alto IA Frank Kliegl John Heddinger Signed (1) The employer does not elect the employers’ liability coverage. Corey Gramowski gramowski@windstream.net Self Emmetsburg Palo Alto IA Frank Kliegl John Heddinger Signed
1359 2022-11-04 10:48 Anonymous (not verified) 173.18.22.217 Lewis Enterprises Limited Liability Company 2723 Witmer Street Des Moines Ia 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-04 Corey Lewis coreyboy1990@gmail.com Des Moines Polk Iowa Kelly Coluzzi Erick Schuldt Signed (1) The employer does not elect the employers’ liability coverage. Corey Lewis coreyboy1990@gmail.com Owner Des Moines Polk Iowa Kelly Coluzzi Erick Schuldt Signed
399 2021-02-15 14:44 Anonymous (not verified) 192.30.185.142 Poss Concrete Proprietorship 3106 Dodge Ave, Sioux City, IA 51106 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-15 Corey Poss coreyposs1@gmail.com Sioux City Woodbury IA Katie Jenks Nate Blaeser Signed (1) The employer does not elect the employers’ liability coverage. Corey Poss coreyposs1@gmail.com Owner Sioux City Woodbury IA Katie Jenks Nate Blaeser Signed
870 2022-01-28 15:51 Anonymous (not verified) 63.229.189.35 Cory Anderson Proprietorship 2234 141st St, Fort Dodge, IA 50501 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-28 Cory Anderson coryleeanderson@yahoo.com Fort Dodge Webster Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Cory Anderson abigail@rickmilesartisans.com Self Fort Dodge Webster Iowa Abigail Miles Alex Miles Signed
1007 2022-03-25 10:30 Anonymous (not verified) 208.73.53.194 Cory Lehman Proprietorship 2428 Keokuk Drive 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. 2022-03-25 Cory Lehman corysfloors@hotmail.com Pella Marion Iowa Trisha K Klok Terri Van Ryswyk Signed (1) The employer does not elect the employers’ liability coverage. Cory Lehman corysfloors@hotmail.com Self Pella Marion Iowa Trisha K Klok Terri Van Ryswyk Signed
1490 2023-03-03 10:31 Anonymous (not verified) 94.188.205.175 Bagby Lawncar and More Limited Liability Company 921 Pleasant Street, Des Moines IA 50309 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-03 Cory Michael Bagby bagbylawncareandmore@gmail.com 921 Pleasant Street Polk Iowa Kelly Coluzzi Erick Schuldt Signed (1) The employer does not elect the employers’ liability coverage. Cory Bagby babylawncareandmore@gmail.com Owner Des Moines Polk Iowa Kelly Coluzzi Erick Schuldt Signed
1627 2023-05-08 13:43 Anonymous (not verified) 94.188.205.169 CR TOTAL PLUMBING, INC. Limited Liability Company 8190 Southern Hills Circle, Dubuque, IA 52003 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-05 Cory Ranson crpipes2@yahoo.com Dubuque Dubuque Iowa Randi Taylor Michelle Woodman Signed (1) The employer does not elect the employers’ liability coverage. CR Total Plumbing, Inc crpipes2@yahoo.com Owner Dubuque Dubuque Iowa Randi Taylor Michelle Woodman Signed
1201 2022-07-11 20:19 Anonymous (not verified) 108.59.100.21 Craig A Selberg dba Selberg Construction Proprietorship 853 North Fork Hollow Rd, Waukon IA 52172 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-11 Craig A Selberg selberg.construction65@gmail.com Waukon Allamakee Iowa Jane M Regan Nancy K Bechtel Signed (1) The employer does not elect the employers’ liability coverage. Craig A Selberg selberg.construction65@gmail.com Employer/Owner Waukon Allamakee Iowa Jane M Regan Nancy K Bechtel Signed
984 2022-03-18 11:34 Anonymous (not verified) 207.177.116.48 Craig Jacoba Signs Proprietorship 20404 Walnut Street Yarmouth, IA 52660 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-18 Craig Allan Jacoba craigjacoba1@hotmail.com Yarmouth Des Moines Iowa Amy Moyner Brenda Levitt Signed (1) The employer does not elect the employers’ liability coverage. Craig Jacoba craigjacoba1@gmail.com subcontractor Yarmouth Des Moines Iowa Amy Moyner Brenda Levitt Signed
985 2022-03-18 11:39 Anonymous (not verified) 207.177.116.48 Craig Jacoba Signs Proprietorship 20404 Walnut Street Yarmouth, IA 52660 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-18 Craig Allan Jacoba craigjacoba1@hotmail.com Yarmouth Des Moines Iowa Amy Moyner Brenda Levitt Signed (1) The employer does not elect the employers’ liability coverage. Greater Burlington Partnership - Chamber of Commerce amoyner@greaterburlington.com subcontractor Burlington Des Moines Iowa Amy Moyner Brenda Levitt Signed
1851 2023-09-22 12:36 Anonymous (not verified) 94.188.207.229 MNM Construction Proprietorship 3224 sw 12th place des moines iowa 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-22 craig allen mccormick craigmccormick.6363@gmail.com Des Moines Iowa Iowa Tara Murphy Kristie Hubbard Signed (1) The employer does not elect the employers’ liability coverage. craig mccormick craigmccormick.6363@gmail.com self Des Moines Iowa Iowa Tara Murphy Kristie Hubbard Signed
485 2021-04-16 11:58 Anonymous (not verified) 69.57.23.123 CRAIG AUKES Proprietorship 43397 50TH AVENUE, BUFFALO CENTER, IA 50424 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-16 CRAIG AUKES cdaukes@yahoo.com Buffalo Center Winnebago Iowa Steven Heyer Cindy Mawdsley Signed (1) The employer does not elect the employers’ liability coverage. CRAIG AUKES cdaukes@yahoo.com Employer-Proprietor Buffalo Center Winnebago IA Steven Heyer Cindy Mawdsley Signed
1229 2022-07-26 15:56 Anonymous (not verified) 173.31.102.238 Rai Neu Jo LLC Limited Liability Company 957 Westwood Dr NW Cedar Rapids, Iowa 52405 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-26 Craig Edward Johnson cejohnson119@yahoo.com Cedar Rapids Linn Iowa Becky Lynn Johnson Patricia Ann Coghlan Signed (1) The employer does not elect the employers’ liability coverage. Craig Edward Johnson cejohnson119@yahoo.com Same person Cedar Rapids Linn Iowa Becky Lynn Johnson Patricia Ann Coghlan 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
1877 2023-10-23 15:49 Anonymous (not verified) 94.188.207.228 Craig Michael Wilson Proprietorship 24538 118th Street, Columbus Junction, IA 52738 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Craig Michael Wilson tripod109@hotmail.com Columbus Junction Louisa IA Brenda Wilson Ruger Dean Signed (1) The employer does not elect the employers’ liability coverage. Craig Michael Wilson tripod109@hotmail.com Self Columbus Junction Louisa IA Brenda Wilson Ruger Dean Signed
1391 2022-12-12 11:13 Anonymous (not verified) 136.35.255.41 Snyder Roofing Proprietorship 2343 ridge trail 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. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-12-12 Craig Snyder snyderroofingcr@gmail.com Cedar Rapids Linn county Iowa Jordan Loyd Charles Wood Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay Missouri Charles Wood Jordan Loyd Signed
1218 2022-07-21 10:55 Anonymous (not verified) 173.27.17.3 LeafFilter North LLC Proprietorship Bettendorf I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-21 Craig Stang stangcraig@gmail.com Silvis Rock island IL Cody Dunbar Tiffani Branham Signed (1) The employer does not elect the employers’ liability coverage. LeafFilter North LLC cdunbar@leaffilter.com Install manager Bettendorf Iowa United States Cody dunbar Tiffani Branham Signed
1227 2022-07-26 09:20 Anonymous (not verified) 173.27.17.3 LeafFilter North LLC Proprietorship 866 40th Ave bettendorf IA 52722 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-26 Craig Stang stangcraig@gmail.com Moline Rock island IL Cody Dunbar Tiffani Branham Signed (1) The employer does not elect the employers’ liability coverage. LeafFilter North LLC cdunbar@leaffilter.com Install manager Bettendorf Iowa United States Cody dunbar Tiffani Branham Signed
1091 2022-05-06 09:54 Anonymous (not verified) 97.127.228.168 American Concrete Proprietorship 2629 Sheffield dr. Davenport iowa 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. 2022-05-06 Craig wells craiglwells@hotmail.com Davenport Scott Iowa Kristin frymoyer Cameron anderson Signed (1) The employer does not elect the employers’ liability coverage. DK home products anne@dkhomeproducts.com Sub contractor Davenport Scott Iowa Kristin frymoyer Cameron anderson Signed
1753 2023-07-18 14:41 Anonymous (not verified) 94.188.205.168 Cruz Lerma Proprietorship 1439 17th Ct Des Moines, Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-18 Cruz Lerma deb@picowa.com Des Moines Polk Iowa Deb Stratton Kelly K Denger Signed (1) The employer does not elect the employers’ liability coverage. Cruz Lerma deb@piciowa.com self Des Moines Polk Iowa Deb Stratton Kelly K Denger Signed
1070 2022-04-26 09:35 Anonymous (not verified) 174.198.72.171 Boyz Roofing LLC Limited Liability Company 802 E County Lane Rd Lot 25 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-26 Cupertino Rodriguez Hernandez christopherrodriguez091889@gmail.com Des Moines Polk Iowa Yoselin Morales Manny Sokop Signed (1) The employer does not elect the employers’ liability coverage. Cupertino Rodriguez Hernandez christopherrodriguez091889@gmail.com Owner Des Moines Polk Iowa Yoselin Morales Manny Sokop Signed
266 2020-09-21 18:08 Anonymous (not verified) 174.126.94.77 Club Fantasy Inc. Limited Liability Company P.O. Box 5115 Sioux City Iowa 51102 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-21 Curtis A. Behr cacbehr@aol.com Sioux City Woodbury Iowa Carter Vahle Dawn Meyer Signed (1) The employer does not elect the employers’ liability coverage. Curtis A. Behr cacbehr@aol.com Self Sioux City Woodbury Iowa Carter Vahle Dawn Meyer Signed
804 2021-12-16 21:51 Anonymous (not verified) 98.21.205.195 Kustom Home Improvements Proprietorship 400 Davidson st New Virginia Iowa 50210 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-16 Curtis Allen Masterson kustomhomeimprovements.dk@gmail.com New Virginia Warren Iowa Cindy Sue Gyles Shantell Christine Rice Signed (1) The employer does not elect the employers’ liability coverage. David Jack Kimmel kustomhomeimprovements.dk@gmail.com Self New Virginia Warren Iowa Cindy Sue Gyles Shantell Christine Rice Signed
2182 2024-04-25 19:37 Anonymous (not verified) 94.188.205.174 Curtis Bunnell sub contractor Proprietorship 907 s main st sigourney IA 52591 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-23 CURTIS BUNNELL curt3551.cb@gmail.com Sigourney Keokuk IA Latisha Bunnell Wendy Yeo Signed (1) The employer does not elect the employers’ liability coverage. Curtis bunnell curt3551.cb@gmail.com Same person Sigourney Keokuk IA Latisha bunnell Wendy Yeo Signed
1472 2023-02-20 15:52 Anonymous (not verified) 94.188.207.230 C & A Fox Farms LLC Limited Liability Company 3275 Valley Ave Orchard IA 50460 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-20 Curtis Fox sales@foxfarmsllc.com Orchard IOWA United States Darrel Elsbernd Chris Fye Signed (1) The employer does not elect the employers’ liability coverage. Curtis Fox sales@foxfarmsllc.com Self Orchard IOWA United States Darrel Elsbernd Chris Fye Signed
1013 2022-03-28 14:54 Anonymous (not verified) 74.115.101.41 Curt Hudson DBA C & L Trucking Partnership 44651 120th Ave Laurens, IA 50554 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-28 Curtis Hudson clhudson@ncn.net Laurens Pocahonta IA Dale Eng Troy Rubel Signed (1) The employer does not elect the employers’ liability coverage. Curtis Hudson clhudson@ncn.net self Laurens Pocahontas IA Dale Eng Troy Rubel Signed
1683 2023-06-09 07:11 Anonymous (not verified) 94.188.207.226 Daves Boys Moving and Hauling LLC Limited Liability Company 264 Derbyshire Rd. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-09 Curtis Lane Curtis@davesboys.com Waterloo Blackhawk County IA Shelley Caughron Macray Caughron Signed (1) The employer does not elect the employers’ liability coverage. Curtis Lane Curtis@davesboys.com Myself Waterloo Blackhawk IA Shelley Caughron Macray Caughron Signed
405 2021-02-17 11:04 Anonymous (not verified) 104.201.67.178 CYE Painting Limited Liability Company 5202 SE 31st Ct Des Moines,IA 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-17 CYE Painting marilopez9657@yahoo.com Des Moines Polk Iowa Maricela Lopez Cruz Cabrera Signed (1) The employer does not elect the employers’ liability coverage. Maricela Lopez marilopez9657@yahoo.com N/a Des Moines Polk IA Maricela Lopez Cruz Cabrera Signed
1403 2023-01-03 15:23 Anonymous (not verified) 173.20.50.85 Falcon Pride Properties, LLC Limited Liability Company 1401 State Highway 57, Parkersburg, IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-23 D. Jay Ellis cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. D. Jay Ellis cmins_re@mchsi.com Owner Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed
1297 2022-09-07 09:36 Anonymous (not verified) 173.29.47.222 Premiere Plastering & Drywall, Inc. Proprietorship 2331 W. 63rd 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. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-09-07 Dagoberto Nunez nunezdogoberto730@gmail.com Iowa City Johnson Iowa Jamie Wardlow Kandra Blumenshein Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Premiere Plastering & Drywall, Inc. premiere_pd_llc@yahoo.com Subcontractor Davenport Scott Iowa Jamie Wardlow Kandra Blumenshein Signed
1893 2023-11-02 14:39 Anonymous (not verified) 94.188.205.177 Dagoberto Nuñez Proprietorship Iowa city I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-02 Dagoberto Nuñez nunezdagoberto730@gmail.com 833 basswood ln iowa city Johnson IA Darwin salgado Ramon nuñez Signed (1) The employer does not elect the employers’ liability coverage. Dagoberto Nuñez nunezdagoberto730@gmail.com Yo mismo Iowa city Johnson IA Darwin Salgado Ramon nuñez Signed
127 2020-04-24 09:18 Anonymous (not verified) 63.152.82.5 TD Auto Services LLC Limited Liability Company 451 W Parker St Waterloo IA 50703 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-27 Dakoda Sellers dakoda.d.sellers@gmail.com Waverly Bremer IA Jennie Roster Dustin Roster Signed (1) The employer does not elect the employers’ liability coverage. Dakoda D Sellers dakoda.d.sellers@gmail.com Owner Waverly Bremer IA Jennie Roster Dustin Roster Signed
132 2020-04-27 17:26 Anonymous (not verified) 73.94.97.93 Kota Construction Limited Liability Company 52 SE Pembrooke Ln I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-27 Dakota Beaulieu cody.b@buildwithkota.com Waukee IA United States Kyli Torkelson Koray Furrow Signed (1) The employer does not elect the employers’ liability coverage. Dakota Beaulieu cody.b@buildwithkota.com Self Waukee Dallas Iowa Kyli Torkelson Koray Furrow 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
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
117 2020-04-11 09:08 Anonymous (not verified) 72.255.83.134 MIDWEST AG SOLUTIONS, LLC Limited Liability Company 4949 PLEASANT ST, STE 204, WEST DES MOINES, IA 50266 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-11 DALE A EASTMAN dale@emdsm.com Waukee Dallas IA Gary Marshall Brittain Bachus Signed (1) The employer does not elect the employers’ liability coverage. DALE A EASTMAN dale@emdsm.com same WAUKEE DALLAS IA GARY MARSHALL BRITTAIN BACHUS Signed
382 2021-02-02 13:19 Anonymous (not verified) 192.30.185.142 Double D Weatherization Proprietorship 2069 Glenn Ellen Rd, Sergeant Bluff, IA 51054 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-02 Dale Gernhart lakehome@longlines.com Sergeant Bluff Woodbury IA Nate Blaeser Jenni Ebner Signed (1) The employer does not elect the employers’ liability coverage. Dale Gerhart lakehome@longlines.com Self Sergeant Bluff Woodbury IA Nate Blaeser Jennie Ebner Signed
54 2020-02-06 14:18 Anonymous (not verified) 173.28.28.57 Dale Hansman dba Klinkenborg Hansmann Law Office Proprietorship 1201 Hwy 57, Parkersburg, IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-14 Dale Hansmann cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Dale Hansmann cmins_re@mchsi.com Self Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed
1964 2023-12-22 10:19 Anonymous (not verified) 94.188.207.224 Dale Pahl Proprietorship 711 N. 1St. B105 Eldridge IA 52748 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-21 Dale Pahl Pada7910@gmail.com Eldridge Scott Iowa Samantha weston Rick mayerhofer Signed (1) The employer does not elect the employers’ liability coverage. Dale Pada7910@gmail.com Self Eldridge Scott IA Samantha weston Rick Mayerhofer Signed
915 2022-02-15 16:43 Anonymous (not verified) 199.247.79.215 Dale B Wetherell Trucking Proprietorship 5844 40th Ave., Alta, IA 51002 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-15 Dale Wetherell barbw@sppinsurance.com Alta Iowa Iowa Barbara Wetherell Kelli Turnquist Signed (1) The employer does not elect the employers’ liability coverage. Dale Wetherell barbw@sppinsurance.com Self Alta Buena Vista IA - Iowa Barb Wetherell Kelli Turnquist Signed
965 2022-03-10 12:44 Anonymous (not verified) 107.115.239.27 KG Land Works LLC Limited Liability Company P.O. Box 931 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-10 Dalton Gregory Gardner kglandworks@gmail.com Barnsdall Osage Oklahoma Dalton Gardner Colton Kelley Signed (1) The employer does not elect the employers’ liability coverage. Dalton Gardner kglandworks@gmail.com Owner Barnsdall Osage Oklahoma Dalton Gardner Colton Kelley Signed
1963 2023-12-18 14:45 Anonymous (not verified) 94.188.207.227 Elite Excavation Services Limited Liability Company 13335 Amber Rd X44 Anamosa Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-18 Dalton Starn eliteexcavationservices97@gmail.com Anamosa Jones Iowa Chase miller Nathan Decker Signed (1) The employer does not elect the employers’ liability coverage. Dalton Starn eliteexcavationservices97@gmail.com Owner Anamosa Jones Iowa Chase miller Nathan decker Signed
110 2020-04-06 14:13 Anonymous (not verified) 99.203.98.177 Stifel seasonal services Limited Liability Company 935 4th street waukee I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-06 Dalton Stifel daltonstifel@icloud.com waukee Dallas IA Bryant ternes Tammy stifel Signed (1) The employer does not elect the employers’ liability coverage. Dalton Stifel daltonstifel@icloud.com Owner waukee Dallas IA Bryant Ternes Tammy Stifel Signed
1726 2023-07-07 18:22 Anonymous (not verified) 94.188.205.168 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 Damien Joseph Shull damienshull@gmail.com Omaha Douglas Nebraska Angela Shull John Shull Signed (1) The employer does not elect the employers’ liability coverage. Damien Joseph Shull damienshull@gmail.com Self Omaha Douglas Nebraska Angela Shull John Shull Signed
1916 2023-11-21 12:31 Anonymous (not verified) 94.188.205.174 DC Painting Proprietorship 205 Astor St, Des Moines, IA 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-03 Damion Clement gcort06@gmail.com Des Moines Polk IA Brandi Haight Dennis Clement Signed (1) The employer does not elect the employers’ liability coverage. Damion Clement gcort06@gmail.com Owner 205 Astor Street Polk IA Brandi Haight Dennis Clement Signed
509 2021-05-10 15:25 Anonymous (not verified) 108.190.5.14 Shift Transport LLC Limited Liability Company 4215 Kris Line Drive Waterloo, IA 50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-10 Damir Pajazetovic damirp2015@gmail.com Waterloo Black Hawk Iowa Fata Pajazetovic Melda Pajazetovic Signed (1) The employer does not elect the employers’ liability coverage. Adnan Pajazetovic adoni.shift@gmail.com Owner Waterloo Black Hawk Iowa Fata Pajazetovic Melda Pajazetovic Signed
360 2021-01-12 12:08 Anonymous (not verified) 75.162.189.102 Super Green Plus Llc Limited Liability Company 3020 SE 5th 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. 2021-01-12 Damon Berry theatvfan@gmail.com Des Moines IA United States Naki Brown Nakima Brown Signed (1) The employer does not elect the employers’ liability coverage. Super Green Plus theatvfan@gmail.com owner Des Moines IA United States Naki Brown Nakima Brown Signed
555 2021-07-06 12:06 Anonymous (not verified) 66.188.136.150 Damond Horner Proprietorship 44 East Grove Monroe, MI 48162 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-02 Damond Horner kschumacher@tricorinsurance.com Monroe Monroe MI Mitch Kemp Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Damond Horner kschumacher@tricorinsurance.com Same Monroe Monroe MI Mitch Kemp Cody McClain Signed
1175 2022-07-05 07:56 Anonymous (not verified) 64.251.168.116 Daniel Alan Valburg Proprietorship 27656 SD Hwy 44 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-05 Dan A Valburg agflyer620@gwtc.net White River Mellette SD George Ludvic Julie Ludvik Signed (1) The employer does not elect the employers’ liability coverage. Daniel Alan Valburg agflyer620@gwtc.net proprieter White River mellette SD George Ludvik Julie Ludvik Signed
1036 2022-04-06 10:22 Anonymous (not verified) 67.212.111.166 Precision Painting Proprietorship 507 Broad Street, Reinbeck Iowa 50669 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-06 Dan Bowser dbowser.precision.painting@gmail.com Reinbeck IA United States Kari Houle Steve Swanson Signed (1) The employer does not elect the employers’ liability coverage. Cory Koger coryspainting@gmail.com Self CEDAR FALLS IA United States Kari Houle Steve Swanson Signed
23 2020-01-02 14:54 Anonymous (not verified) 173.17.129.166 Dan Gudenkauf Proprietorship 3277 180th Ave, Ryan, IA 52330 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-02 Dan Gudenkauf dandselectricmotor@gmail.com Ryan Delaware Iowa Nicole Almburg Kevin Corn Signed (1) The employer does not elect the employers’ liability coverage. Dan Gudenkauf dandselectricmotor@gmail.com Owner Ryan Delaware Iowa Nicole Almburg Kevin Corn Signed
1039 2022-04-11 14:33 Anonymous (not verified) 199.120.121.97 Panama Electric Proprietorship 106 S Railway Panama IA 51562 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-11 Dan Wingert danwingert@fmctc.com Panama Shelby IA Laura Wingert Sylvan Kenkel Signed (1) The employer does not elect the employers’ liability coverage. Dan Wingert danwingert@fmctc.com Self Panama Shelby IA Laura Wingert Sylvan Kenkel Signed
53 2020-02-06 11:09 Anonymous (not verified) 65.100.22.228 Bostian Captioning Service, Inc. Proprietorship 712 8th Avenue 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. 2020-02-06 Dana Bostian danabostian@msn.com Oelwein IA United States Lynne Koch Billie Winters Signed (1) The employer does not elect the employers’ liability coverage. Dana Bostian danabostian@msn.com President of Proprietorship Oelwein IA United States Lynne Koch Billie Winters 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
1452 2023-02-13 16:49 Anonymous (not verified) 94.188.207.228 The Wine Shop, LLC Limited Liability Company 305 Main St, Cedar Falls, IA 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2023-02-13 Dana Swasand danaswasand@rocketmail.com Steamboat Rock Hardin Co. Iowa Jay Schares Nicole Erickson Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Dana Swasand danaswasand@rocketmail.com Owner/Member Steamboat Rock Hardin Co. Iowa Jay Schares Nicole Erickson Signed
1886 2023-10-31 15:53 Anonymous (not verified) 94.188.205.176 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 Dane McDonald dane.mcdonald@stellar-solar.net Bondurant 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
445 2021-03-23 12:34 Anonymous (not verified) 172.58.84.232 XD PAINTING Limited Liability Company 1233 Herold 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. 2021-03-23 Daniel Alcaraz Suarez xdpainting@gmail.com Des Moines Polk county Iowa Anthony Maland Marcus Ross Signed (1) The employer does not elect the employers’ liability coverage. Daniel Alcaraz Suarez xdpainting@gmail.com None Des Moines Polk county Iowa Anthony maland Marcus Ross Signed
59 2020-02-11 11:34 Anonymous (not verified) 198.167.182.164 Besch Electric LLC Limited Liability Company 317 Sycamore St, Riverside, IA 52327 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-03 Daniel Besch beschd@hotmail.com Riverside Washington Iowa Steven J Fishman E Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Daniel Besch beschd@hotmail.com Managing Member Riverside Washington Iowa Steven J Fishman E Dyan Kriener Signed
286 2020-10-21 18:32 Anonymous (not verified) 173.218.73.44 Bilyeu Underground LLC Limited Liability Company 1136 W. Irene Ct. Nixa, MO 65714 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-21 Daniel Bilyeu danielbilyeu@gmail.com Nixa Christian Missouri Gary George Bilyeu Chad Anthony Charles Signed (1) The employer does not elect the employers’ liability coverage. Daniel Bilyeu danielbilyeu@gmail.com Owner Nixa Christian Missouri Gary George Bilyeu Chad Anthony Charles Signed
1101 2022-05-13 12:55 Anonymous (not verified) 174.199.102.54 Daniel Blanco Proprietorship 1403 2nd Ave 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. 2022-05-13 Daniel Blanco chindan77@yahoo.com Ft Dodge Webster IA Vanessa Blanco Elva Castañeda Signed (1) The employer does not elect the employers’ liability coverage. Daniel Blanco chindan77@yahoo.com Self Ft Dodge Webster IA Vanessa Blanco Elva Castañeda Signed
1900 2023-11-09 23:24 Anonymous (not verified) 94.188.207.224 Daniel Blanco Proprietorship 1403 2nd Ave 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. 2023-11-09 Daniel Blanco chindan77@yahoo.com Fort Dodge IA United States Vanessa Blanco Jorge Blanco Signed (1) The employer does not elect the employers’ liability coverage. Daniel Blanco chindan77@yahoo.com Self Fort Dodge IA United States Elva Castañeda Vanessa Blanco Signed
1393 2022-12-13 12:45 Anonymous (not verified) 50.82.133.22 Ponderosa Outdoor Limited Liability Partnership 104 Vista Dr Montezuma, Ia 50171 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-13 Daniel Deaver ponderosaoutdoor@gmail.com Altoona Polk Iowa Faith Deaver Jessi Perkins Signed (1) The employer does not elect the employers’ liability coverage. Daniel Deaver ponderosaoutdoor@gmail.com self Altoona Polk Iowa Faith Deaver Jessi Perkins 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
1568 2023-04-12 10:46 Anonymous (not verified) 94.188.205.175 Daniel gramowski Limited Liability Company 2835 raccoon street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-12 Daniel gramowski oneanddoneroofing@gmail.com Des moines Polk Iowa Paige gramowski Cole smith Signed (1) The employer does not elect the employers’ liability coverage. Daniel gramowski oneanddoneroofing@gmail.com Owner Des Moines Polk Iowa Cole smith Paige gramowski 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
2178 2024-04-25 10:56 Anonymous (not verified) 94.188.205.176 Loonpa Landscaping LLC Limited Liability Partnership 5309 Red Oak Ln Cedar Falls, IA 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2024-04-25 Daniel J White danny@barerootslawn.care Cedar Falls Black Hawk iowa Kari White James White Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Daniel J White danny@barerootslawn.care Owner Cedar Falls Black Hawk Iowa James White Kari White Signed
432 2021-03-11 18:17 Anonymous (not verified) 99.196.90.45 A-Z Tree Service Proprietorship 1128 W 124th 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. 2021-03-11 Daniel Keeney dansatoztreeservice@gmail.com Colfax Jasper Iowa David Short Brandon Vriezlaar Signed (1) The employer does not elect the employers’ liability coverage. Daniel Keeney dansatoztreeservice@gmail.com Sole Proprietor Colfax Jasper Iowa David Short Brandon Vriezlaar Signed
373 2021-01-25 09:06 Anonymous (not verified) 66.188.136.150 Daniel Kulberg Proprietorship PO Box 641, Renville, MN 56284 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-25 Daniel Kulberg kschumacher@tricorinsurance.com Renville Renville MN Russell Masartis Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Daniel Kulberg kschumacher@tricorinsurance.com Same Reville Renville MN Russell Masartis Shuree Behr Signed
233 2020-08-17 14:24 Anonymous (not verified) 165.225.0.98 Daniel L Knebel Proprietorship 439 Carroll Blvd, Dunkerton, IA, 50626 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-17 Daniel L Knebel knebeldan@gmail.com Dunkerton Black Hawk Iowa Carman M Knebel Joseph E Knebel Signed (1) The employer does not elect the employers’ liability coverage. Daniel L Knebel knebeldan@gmail.com Owner Dunkerton Black Hawk Iowa Carman M Knebel Joseph E Knebel Signed
325 2020-11-23 11:14 Anonymous (not verified) 174.198.82.169 Dan davidson Limited Liability Company 21Lincoln Dr I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2020-11-22 Daniel Lee davidson unitedremodelingdd@gmail.com Palo Linn IA Daniel Lee davidson Daniel Lee davidson Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Daniel Lee davidson unitedremodelingdd@gmail.com Owner Palo Linn IA Daniel Lee davidson Daniel Lee davidson Signed
1286 2022-08-26 09:09 Anonymous (not verified) 97.125.43.203 Daniel Lugo Proprietorship 1217 Harold 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. 2022-08-24 Daniel Lugo deb@piciowa.com Des Mpines Polk IA Debra Stratton Martin Pinon Signed (1) The employer does not elect the employers’ liability coverage. Daniel LUgo deb@piciowa.com self Des Moines Polk Iowa Debra Stratton Martin Pinon 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
1018 2022-03-29 15:00 Anonymous (not verified) 97.125.143.50 Modified Originals of Winterset Limited Liability Company 128 S 3rd Ave, Winterset, IA 50273 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-29 Daniel Maiers Modifiedoriginals.winterset@gmail.com Winterset Iowa Iowa Mark Haddinger Josh Williams Signed (1) The employer does not elect the employers’ liability coverage. Dan Maiers Modifiedoriginals.winterset@gmail.com Self Winterset Iowa Iowa Mark Haddinger Josh Williamson Signed
620 2021-08-26 16:26 Anonymous (not verified) 75.162.146.246 Daniel Meza Reyes Proprietorship 1640 E Army Post RD Des Moines IA 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-23 Daniel Meza Reyes danielmr9247@gmail.com Des Moines polk IA Yolanda Mendoza Liliana Sanchez Signed (1) The employer does not elect the employers’ liability coverage. Daniel Meza Reyes danielmr9247@gmail.com self Des Moines polk IA Yolanda Mendoza Liliana Sanchez Signed
178 2020-06-08 13:51 Anonymous (not verified) 173.21.16.200 Daniel Mullanack Limited Liability Company 1208 Franklin St. Buffalo, IA 52728 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2020-06-08 daniel mullanack mullanackbuilders@mediacombb.net buffalo scott iowa brandon brooks amy carlson Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. linda mullanack mullanackbuilders@mediacombb.net office manager buffalo scott iowa brandon brooks amy carlson Signed
606 2021-08-17 12:25 Anonymous (not verified) 69.57.199.231 Precision Painting Proprietorship 507 Broad St. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-08-17 Daniel Paul Bowser danshonda12@gmail.com Reinbeck Grundy Iowa David Paul Bowser Mary Ellen Sue Bowser Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Sinnott Agency toms@sinnottagency.com Insurance provider Waterloo Blackhawk Iowa David Paul Bowser Mary Ellen Sue Bowser Signed
607 2021-08-17 12:31 Anonymous (not verified) 69.57.199.231 Precsion Painting Proprietorship 507 Broad 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. 2021-08-17 Daniel Paul Bowser danshonda12@gmail.com Reinbeck Grundy Iowa David Paul Bowser Mary Ellen Sue Bowser Signed (1) The employer does not elect the employers’ liability coverage. Sinnott Agency toms@sinnottagency.com Insurance provider Waterloo Blackhawk Iowa David Paul Bowser Mary Ellen Sue Bowser Signed
1340 2022-10-18 17:03 Anonymous (not verified) 166.181.89.97 Stevens mobile welding services LLC Limited Liability Company 5645 se 56th st. Carlisle, IA 50047 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-18 Daniel Robert Stephens dannystephens303@gmail.com Carlisle Polk Iowa Nikita Marie Knapp Stacy Robin Stephens Signed (1) The employer does not elect the employers’ liability coverage. Daniel Robert Stephens dannystephens303@gmail.com Owner Carlisle Polk Iowa Nikita Marie Knapp Stacy Robin Stephens Signed
1269 2022-08-18 16:17 Anonymous (not verified) 67.55.174.140 Roberts Compliance Services, LLC Limited Liability Company 405 Hilltop 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. 2022-08-18 Daniel Roberts dan@robertscompliance.com Stanton Montgomery IA Robert Schenck Pier Osweiler Signed (1) The employer does not elect the employers’ liability coverage. Daniel Roberts dan@robertscompliance.com self Stanton Montgomery IA Robert Schenck Pier Osweiler 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
1907 2023-11-15 09:45 Anonymous (not verified) 94.188.205.168 Dan Taylor Proprietorship 1422 State ST. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-15 Daniel Taylor mailrunner1958@gmail.com Mason City Cerro Gordo IA Bob Smith Dave Clark Signed (1) The employer does not elect the employers’ liability coverage. Daniel Taylor mailrunner1958@gmail.com employee Mason City Cerro Gordo IA Bob Smith Dave Clark 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
642 2021-09-17 11:09 Anonymous (not verified) 167.142.95.56 Preferred Properties of Iowa, Inc. Limited Liability Company 500 W. Temple 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. 2021-09-17 Daniel Zech dan.ppi@gmail.com Lenox Taylor Iowa Ron Travis Maury Moore Signed (1) The employer does not elect the employers’ liability coverage. Dan Zech dan.ppi@gmail.com Owner Lenox Taylor Iowa Ron Travis Maury Moore Signed
781 2021-12-08 08:41 Anonymous (not verified) 172.58.87.49 Diggins Installations Proprietorship 1619 48th st Des moines ia 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-06 Danny Allan Diggins ddigdan@gmail.com Des Moines Polk 1619 48th st Nancy Davis Angie Pilcher Signed (1) The employer does not elect the employers’ liability coverage. Danny Diggins ddigdan@gmail.com Self Des moines Polk Ia Nancy Davis Angie pilcher Signed
1784 2023-08-04 10:39 Anonymous (not verified) 94.188.205.175 Danny Davis Limited Liability Company 2733 Raccoon Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-04 Danny R Davis ddavis3243@yahoo.com Des Moines IA United States Michael Gatewood Brad Wheeler Signed (1) The employer does not elect the employers’ liability coverage. HD EXTERIORS LLC ddavis3243@yahoo.com Owner Des Moines IA United States Michael Gatewood Brad Wheeler Signed
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
1622 2023-05-01 16:05 Anonymous (not verified) 94.188.205.174 Danny Shineflew Proprietorship 103th 10street West Des Moines I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-01 Danny Shineflew dannyshineflew@gmail.com West Des Moines Polk Iowa Tony Ekman Dustin Hogan Signed (1) The employer does not elect the employers’ liability coverage. Danny Shineflew dannyshineflew@gmail.com self West Des Moines Polk Iowa Tony Ekman Dustin Hogan Signed
507 2021-05-10 10:20 Anonymous (not verified) 192.30.186.37 Stowe's Drywall Proprietorship PO Box 712, Ponca, NE 68776 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-10 Danny Stowe deb.nana.stowe@gmail.com Ponca Dixon NE Katie Jenks Virginia Anderson Signed (1) The employer does not elect the employers’ liability coverage. Danny Stowe deb.nana.stowe@gmail.com Owner Ponca Dixon NE Katie Jenks Virginia Anderson Signed
664 2021-10-05 15:01 Anonymous (not verified) 174.242.226.8 New Face Renovations Limited Liability Company 3563 Richland Circle Van Meter, 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. 2021-10-05 Darin Benjamin Davis newfacereno@gmail.com Van Meter Dallas Iowa Ryan Young Betsy Davis Signed (1) The employer does not elect the employers’ liability coverage. Renda Building megemo@commdatalink.com Installer Grimes Polk Iowa Ryan Young Betsy Davis Signed
48 2020-01-29 13:52 Anonymous (not verified) 97.64.170.98 DARIN J. KESSLER Proprietorship 1236 25TH ST AMES, IA 50010 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-29 DARIN J. KESSLER darinjkessler@gmail.com AMES STORY IOWA HEATHER DIANNE LANNING JENNY ANN ARENDS Signed (1) The employer does not elect the employers’ liability coverage. DARIN J. KESSLER darinjkessler@gmail.com SELF AMES STORY IOWA HEATHER DIANNE LANNING JENNY ANN ARENDS Signed
560 2021-07-08 08:46 Anonymous (not verified) 66.188.136.150 Darius Harvey Proprietorship 2738 E 53rd. Apt. 7 Davenport, IA 52807 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-07 Darius Harvey kschumacher@tricorinsurance.com Davenport Scott IA Mitch Kemp Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Darius Harvey kschumacher@tricorinsurance.com Same Davenport Scott IA Mitch Kemp Shuree Behr Signed
299 2020-10-30 10:47 Anonymous (not verified) 216.51.132.207 Kregel Farm Partnership LLP Limited Liability Partnership 30392 Garber RD Guttenberg, IA 52052 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-09 Darlene Kregel TRAVIS.KREGEL@GMAIL.COM Guttenberg Clayton Iowa Jerry J Rochford Nicole L Parker Signed (1) The employer does not elect the employers’ liability coverage. Darlene Kregel TRAVIS.KREGEL@GMAIL.COM owner Guttenberg Clayton Iowa Jerry J Rochford Nicole L Parker Signed
2072 2024-03-01 11:27 Anonymous (not verified) 94.188.207.226 SoldFast Real Estate L.L.C. Limited Liability Company 5525 Meredith Drive Des Moines, Iowa 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-02 Darlyn Fructuoso thejjscleaningllc@gmail.com Des Moines Polk IA Beatriz Musselman Darlyn Fructuoso Signed (1) The employer does not elect the employers’ liability coverage. Cody Wilkinson cody@soldfast.com Contractor Des Moine Polk IA Beatriz Musselman Darlyn Fructuoso 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
1185 2022-07-06 15:12 Anonymous (not verified) 149.20.238.108 Shelby County Fair Corporation Limited Liability Company 314 4th St. Harlan, IA 51537 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-06 Darren Goshorn shelbycountyfair@fmctc.com Harlan Shelby Iowa Kate Heese Katie Petersen Signed (1) The employer does not elect the employers’ liability coverage. Darren Goshorn shelbycountyfair@fmctc.com Board Member Harlan Shelby IA Kate Heese Katie Petersen Signed
614 2021-08-20 12:20 Anonymous (not verified) 172.58.235.242 Darren Qualls Proprietorship 1515 Dewitt St. Ellsworth. IA 50075 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-20 Darren Wade Qualls d.qualls@outlook.com Ellsworth Hamilton IA Jeannie Kathleen Qualls Andrea Littleton Signed (1) The employer does not elect the employers’ liability coverage. Darren Wade Qualls d.qualls@outlook.com Self/Proprietor Ellsworth IA IA Jeannie Kathleen Qualls Andrea Littleton Signed
135 2020-04-28 10:04 Anonymous (not verified) 74.84.101.138 W.A.D.E., Inc. DBA Decorah Cleaners Proprietorship 504 Heivly Street Decorah, IA 52101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-23 Darrin Walter chelsea.whalen@upperiowains.com Decorah Winneshiek IA Robin C Schultz Chelsea Whalen Signed (1) The employer does not elect the employers’ liability coverage. Darrin Walter chelsea.whalen@upperiowains.com Owner Decorah Winneshiek IA Robin C Schultz Chelsea Whalen Signed
1564 2023-04-11 09:15 Anonymous (not verified) 94.188.205.174 Darryl Kinnard Proprietorship 60 Miller Avenue Southwest #13, Cedar Rapids, IA 52404, United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-11 Darryl Kinnard darryl186d@icloud.com Cedar Rapids Linn County Iowa Jordan Nisiewicz Jordan Loyd Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay Missouri Jordan Loyd Robert Snyder Signed
1653 2023-05-18 09:45 Anonymous (not verified) 94.188.205.166 Darwin Gonzales Rodriguez Proprietorship 511 5th Street NE Belmond IA 50421 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-10 Darwin Gonzales Rodriguez office.seamlesspros@icloud.com Belmond Wright Iowa Soila Perez Keith Clabaugh Signed (1) The employer does not elect the employers’ liability coverage. Darwin Gonzales Rodriguez office.seamlesspros@icloud.com Self Belmond Wright Iowa Soila Perez Keith Clabaugh 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
1089 2022-05-05 15:49 Anonymous (not verified) 173.18.22.217 Dave Brecht Lawn Care Limited Liability Company 5213 SE 27th St 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. 2022-05-05 Dave Brecht Fagenmich@gmail.com Des Moines Polk IA Lesa Reeves Mitch Coluzzi Signed (1) The employer does not elect the employers’ liability coverage. Dave Brecht Fagenmich@gmail.com Owner Des Moines Polk IA Lesa Reeves Mitch Coluzzi 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
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
175 2020-06-05 15:14 Anonymous (not verified) 98.21.202.208 Bloomfield Properties LLC Limited Liability Company 206 Weaver Road, Bloomfield, IA 52537 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-05 Dave Lawrence terri_roberts58@yahoo.com Ottumwa Wapello Iowa Sheri Moore Cassidy Dimmitt Signed (1) The employer does not elect the employers’ liability coverage. Terri Roberts terri_roberts58@yahoo.com shareholder Ottumwa Wapello Iowa Sheri Moore Cassidy Dimmitt Signed
1936 2023-12-04 10:22 Anonymous (not verified) 94.188.205.174 Turkey River Ag Sales LLC Limited Liability Company 614 Vernon Rd. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-04 David Ahern davidahern@turkeyriverag.com Cresco IOWA IOWA Michelle Ahern Alyse Ahern Signed (1) The employer does not elect the employers’ liability coverage. Turkey River Ag Sales LLC davidahern@turkeyriverag.com Owner Cresco Howard Iowa Michelle Ahern Alyse Ahern Signed
2018 2024-02-01 15:23 Anonymous (not verified) 94.188.205.177 SolQ, LLC Limited Liability Company 184 N 100 E STE A Logan, UT 84321 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-01 David Bean dave@solq.com Clarkston Cache Utah Perry M. Koger Rebecca Koger Signed (1) The employer does not elect the employers’ liability coverage. David Bean dave@solq.com Owner Logan Cache Utah Perry M. Koger Rebecca Koger Signed
566 2021-07-08 14:19 Anonymous (not verified) 50.82.130.211 Black Cat Ice Cream, LLC Limited Liability Company 1031 Office Park Road, Suite #4, West Des Moines IA 50265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-10 David Boelman cmins_re@mchsi.com Des Moines Polk Iowa Mary Brown Kaytee Stearns Signed (1) The employer does not elect the employers’ liability coverage. Black Cat Ice Cream, LLC cmins_re@mchsi.com Self Des Moines Polk Iowa Mary Brown Kaytee Stearns Signed
605 2021-08-16 16:06 Anonymous (not verified) 67.55.155.46 COMPLETE CONSTRUCTION SERVICES LLC Limited Liability Company 718 FOX RUN I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-16 DAVID BOWER BOWERD@OSKYCSD.ORG OSKALOOSA MAHASKA IOWA JAMES MCNAUL CINDY STEVENSON GRUBB Signed (1) The employer does not elect the employers’ liability coverage. DAVID BOWER BOWERD@OSKYCSD.ORG PRESIDENT OSKALOOSA MAHASKA IOWA JAMES MCNAUL CINDY STEVENSON GRUBB Signed
172 2020-06-02 15:56 Anonymous (not verified) 66.188.136.150 David Bull Proprietorship 221 N Aarlocker St. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-02 David Bull kschumacher@tricorinsurance.com Mount Hope Grant WI Russell Masartis Nancy Wortley Signed (1) The employer does not elect the employers’ liability coverage. David Bull kschumacher@tricorinsurance.com Same Mount Hope Grant WI Russell Masartis Nancy Wortley Signed
1465 2023-02-17 15:05 Anonymous (not verified) 94.188.207.228 Big roofing Proprietorship 114 sw 58th dr I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-17 David Christiansen Mattc@bigroofing515.com Des moines Polk IA STEVE BIEGHLER Jordan walkup Signed (1) The employer does not elect the employers’ liability coverage. Matt christiansen Mattc@bigroofing515.com Self Des moines County Ia Steve bieghler Jordan walkup Signed
1797 2023-08-14 09:37 Anonymous (not verified) 94.188.205.175 SCG Limited Liability Company 307 Bridge St. Redfield, IA 50233 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-01 David Dwight Willis d.dubbaits@yahoo.com Redfield Dallas Iowa Lindsey Willis Sam Samuelson Signed (1) The employer does not elect the employers’ liability coverage. Ross Turner RTurner@holmesmurphy.com Agent Waukee Dallas Iowa Brain Paterson Brandon DeGroff Signed
936 2022-02-25 10:47 Anonymous (not verified) 173.215.112.17 Arganbright Home Construction LLC Limited Liability Company 2251 Soldier Trail, Panora, IA 50216 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-25 David E Arganbright davearganbright@netins.net Panora Guthrie IA Cindy J Carstens Andrew Randol Signed (1) The employer does not elect the employers’ liability coverage. Christine M Arganbright chrisbia@netins.net Member Panora Guthrie IA Cindy J Carstens Andrew Randol Signed
214 2020-07-22 14:31 Anonymous (not verified) 66.188.136.150 David Fuller Proprietorship 19 Riviera Lane, Omro, WI 54963 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-14 David Fuller kschumacher@tricorinsurance.com Omro Winnebago WI Russell Masartis Nancy Wortley Signed (1) The employer does not elect the employers’ liability coverage. David Fuller kschumacher@tricorinsurance.com Same Omro Winnebago WI Russell Masartis Nancy Wortley Signed
1658 2023-05-23 09:56 Anonymous (not verified) 94.188.205.168 M&D Webster Construction Inc Proprietorship 1012 Creek Street Webster City IA 50595 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-28 David Gomez office.seamlesspros@icloud.com Webster City Hamilton Iowa Jessica Knutson Keith Clabaugh Signed (1) The employer does not elect the employers’ liability coverage. David Gomez office.seamlesspros@icloud.com Self Webster City Hamilton Iowa Jessica Knutson Keith Clabaugh Signed
1947 2023-12-07 16:01 Anonymous (not verified) 94.188.205.176 Reinier Construction LLC Limited Liability Company 1406 Linden Lane I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-07 David J Reinier reinierconst@aol.com Des Moines Polk IA PEGGY A ROHDE Douglas E Rohde Signed (1) The employer does not elect the employers’ liability coverage. PEGGY A ROHDE dnprohde@msn.com Bookkeeper Polk City Polk IA Douglas E Rohde Stacie L Miller Signed
801 2021-12-16 21:35 Anonymous (not verified) 98.21.205.195 Kustom Home Improvements Proprietorship 400 Davidson st new Virginia Iowa 50210 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-16 David Jack Kimmel kustomhomeimprovements.dk@gmail.com New Virginia Warren Iowa Cindy Sue Gyles Shantell Christine Rice Signed (1) The employer does not elect the employers’ liability coverage. David Jack Kimmel kustomhomeimprovements.dk@gmail.com Self New Virginia Warren Iowa Cindy Sue Gyles Shantell Christine Rice Signed
2077 2024-03-06 11:08 Anonymous (not verified) 94.188.205.177 Randy's all Right painting Proprietorship 24531n.ave Dallas center iowa po 445 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-06 David keasey keaseyshideaway@gmail.com Dallas center Dallas Iowa Angela Johnston Robin Vilz Signed (1) The employer does not elect the employers’ liability coverage. David keasey keaseyshideaway@gmail.com Self Dallas center Dallas Iowa Angela Johnston Robin Volz Signed
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
383 2021-02-03 15:05 Anonymous (not verified) 50.82.130.211 David Kuehner Proprietorship P.O. Box 158, Allison IA 50602 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-08 David Kuehner cmins_re@mchsi.com Allison Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. David Kuehner cmins_re@mchsi.com Self Allison Butler Iowa Chad Campbell Roxanne Kolder 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
572 2021-07-13 09:59 Anonymous (not verified) 173.27.17.202 David Lochner Proprietorship 866 40th ave Bettendorf Iowa 52722 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-13 David Lochner jnagel@leafhome.com Dubuque Dubuque Iowa Jacob Nagel Shawn Cowell Signed (1) The employer does not elect the employers’ liability coverage. David Lochner jnagel@leafhome.com Self Dubuque Dubuque Iowa Jacob Nagel Shawn Cowell Signed
29 2020-01-06 13:44 Anonymous (not verified) 108.178.203.226 MULLIS CATTLE LLC Limited Liability Company 2506 155TH ST, EARLVILLE IA 52041 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-06 DAVID MULLIS JAMES@CIOIA.COM EARLVILLE DELAWARE IOWA MERRI MOSER BRITTANY LANSING Signed (1) The employer does not elect the employers’ liability coverage. DAVID MULLIS JAMES@CIOIA.COM OWNER EARLVILLE DELAWARE IOWA MERRI MOSER BRITTANY LANSING Signed
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
163 2020-05-20 11:58 Anonymous (not verified) 173.27.1.111 David Proprietorship 4023 E 28th st 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-20 David Ortiz jdiconstrucction@gmail.com Des Moines Polk County Iowa Erika Olague Jieldh Ortiz-Olague Signed (1) The employer does not elect the employers’ liability coverage. David Ortiz jdiconstrucction@gmail.com JDI Construction Des Moines Polk County Iowa Erika Olague Jieldh Ortiz-Olague Signed
1309 2022-09-15 09:58 Anonymous (not verified) 96.31.1.206 PATTONS POWDER COATING Limited Liability Company 421 W MAPLE DRIVE HARTLEY IA 51346 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-15 DAVID PATTON PATTONSPOWDERCOATING@GMAIL.COM HARTLEY OBRIEN IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. PATTONS POWDER COATING - DAVID PATTON PATTONSPOWDERCOATING@GMAIL.COM SELF HARTLEY OBRIEN IOWA TAMI KLEIN JENNIFER YOUNG WIRTH Signed
130 2020-04-27 10:36 Anonymous (not verified) 66.188.136.150 David Roberts Proprietorship 2600 Butterfield, PO Box 3251 Dubuque, IA 52004 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-24 David Roberts buman6578@gmail.com Dubuque Dubuque IA Russell Masartis Angie Olds Signed (1) The employer does not elect the employers’ liability coverage. David Roberts kschumacher@tricorinsurance.com Owner Operator is Employer Dubuque Dubuque IA Russell Masartis Angie Olds Signed
1798 2023-08-14 12:16 Anonymous (not verified) 94.188.207.223 David Robles Proprietorship 3912 E 23rd St Des Moines, Iowa 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-09 David Robles deb@piciowa.com Des Moines Polk Iowa Debra E Stratton Kelly K Denger Signed (1) The employer does not elect the employers’ liability coverage. David Robles deb@piciowa.com self Des Moines Polk Iowa Kelly K Denger Debra E Stratton Signed
1524 2023-03-20 09:00 Anonymous (not verified) 94.188.205.177 David Roman Proprietorship 8350 EP True Parkway, Apt 1101, West Des Moines, IA 50266 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-20 David Roman vida8147@gmail.com West Des Moines Dallas IA Dario Lucas Barrera Alfonso Montoya Signed (1) The employer does not elect the employers’ liability coverage. David Roman vida8147@gmail.com Self West Des Moines Dallas IA Dario Lucas Barrera Alfonso Montoya Signed
1108 2022-05-16 16:14 Anonymous (not verified) 4.4.30.34 David Sickels Proprietorship 2221 Radcliffe Drive SW, Cedar Rapids, IA 52404 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-16 David Sickels glsickels@gmail.com Cedar Rapids IA United States Chad Allen Taylor Steven Thomas Dunn Signed (1) The employer does not elect the employers’ liability coverage. David Allen Sickels glsickels@gmail.com self Cedar Rapids Linn Iowa Chad Allen Taylor Steven Thomas Dunn Signed
1940 2023-12-05 15:11 Anonymous (not verified) 94.188.207.227 David Sickels Proprietorship 2221 Radcliffe drive s.w 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. 2023-11-05 David Sickels davidasickels@gmail.com Cedar rapids Linn Iowa Chad Allen Taylor Steven Thomas Dunn Signed (1) The employer does not elect the employers’ liability coverage. David Allen Sickels davidasickels@gmail.com Self Cedar Rapids Linn Iowa Chad Allen Taylor Steven Thomas Dunn Signed
153 2020-05-12 12:58 Anonymous (not verified) 172.58.86.150 Big Head Burger Limited Liability Company 706 Quincy st. Waterloo, Iowa 50703 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-12 David Westley Bryant questions.bhb@gmail.com Waterloo Black Hawk Iowa Darlean Crawford Everlue Kincaid Signed (1) The employer does not elect the employers’ liability coverage. David Westley Bryant questions.bhb@gmail.com Owner Waterloo Black Hawk Iowa Darlean Crawford Everlue Kincaid Signed
356 2021-01-11 19:39 Anonymous (not verified) 66.188.136.150 David Whitfield Proprietorship 3947 Cracker Cove Lane I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-11 David Whitfield kschumacher@tricorinsurance.com Canal Winchester Fairfield OH Russell Masartis Nancy Wortley Signed (1) The employer does not elect the employers’ liability coverage. David Whitfield kschumacher@tricorinsurance.com Same Canal Winchester Fairfield OH Russell Masartis Nancy Wortley Signed
503 2021-05-05 11:27 Anonymous (not verified) 50.82.130.211 Davonius Reed Limited Liability Company 1913 Upton Avenue, Waterloo IA 50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-01 Davonius Reed cmins_re@mchsi.com Waterloo Black Hawk IA Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Davonius Reed cmins_re@mchsi.com Self Waterloo Black Hawk IA Chad Campbell Roxanne Kolder Signed
1371 2022-11-14 10:55 Anonymous (not verified) 166.181.86.95 Dean Abramczak Proprietorship 524 Nodaway Dr center Point Iowa 52213 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-16 Dean Abramczak gabramczak@gmail.com Center Point IA United States Brenda Oconner Kenny McGraw Signed (1) The employer does not elect the employers’ liability coverage. Dean Abramczak gabramczak@gmail.com I am the only employee I own the company Center Point IA United States Brenda Oconnner Kenny McGraw 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
1305 2022-09-13 14:28 Anonymous (not verified) 166.181.82.226 MarDe's construction Limited Liability Company 5381 16th Ave la porte city ia 50651 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-13 Dean Michael John Martells deanmartells@gmail.com La porte city Benton Ia Sonya Alfreda Mounlavong Cameron Michael Martells Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Regional recruiter Kansas city, mo Clay Missouri Jordan Nisiewicz Jordan Loyd Signed
1606 2023-04-26 11:42 Anonymous (not verified) 94.188.205.166 Dean Petty Proprietorship 309 Locust Street De Soto I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-26 Dean Robert Petty dean.r.petty@gmail.com De Soto Dallas Iowa Sheanah Wright Derek Mullins Signed (1) The employer does not elect the employers’ liability coverage. Dean Robert Petty dean.r.petty@gmail.com Owner 309 Locust Street De Soto Dallas Iowa Sheanah Wright Derek Mullins Signed
1607 2023-04-26 11:42 Anonymous (not verified) 94.188.205.166 Dean Petty Proprietorship 309 Locust Street De Soto I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-26 Dean Robert Petty dean.r.petty@gmail.com De Soto Dallas Iowa Sheanah Wright Derek Mullins Signed (1) The employer does not elect the employers’ liability coverage. Dean Robert Petty dean.r.petty@gmail.com Owner 309 Locust Street De Soto Dallas Iowa Sheanah Wright Derek Mullins Signed
2005 2024-01-29 08:50 Anonymous (not verified) 94.188.207.226 Laser Line Striping Proprietorship 10572 320th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-29 Dean Weikert d.lineuponline@yahoo.com Ackley Iowa United States Linda Weikert Ca Signed (1) The employer does not elect the employers’ liability coverage. Kain Helmke d.lineuponline@yahoo.com D.lineuponline@yahoo.com Ackley Butler Iowa Linda Weikert Kain Helmke Signed
757 2021-11-19 15:11 Anonymous (not verified) 184.80.177.137 Upper Room, LLC Limited Liability Company 1314 9th St SE -Dyersville, 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. 2021-11-19 DeAnne M McCarraher jheims@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The employer does not elect the employers’ liability coverage. Joyce Heims jheims@english-insurance.com agent Dyersville, IA Dubuque Iowa Derrick Parsons Joyce Heims Signed
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
1676 2023-06-02 09:41 Anonymous (not verified) 94.188.207.229 Kacena Family Tree Farm Inc Partnership 2510 55th St., Vinton, IA 52349 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-01 Debra Kacena kacenafarms.alyce@gmail.com Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed (1) The employer does not elect the employers’ liability coverage. Alyce Lynch ashlyn@3riversins.net 25% Owners - President Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed
1066 2022-04-22 11:17 Anonymous (not verified) 50.83.107.151 Delos Steward Proprietorship 1310 w Main Street Marshalltown iowa 50158 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-22 Delos Lyle Steward LDSPlastering2020@gmail.com Marshalltown Marshall Iowa Chris Hart Jody Steward Signed (1) The employer does not elect the employers’ liability coverage. LDS Plastering ldsplastering2020@gmail.com Owner Marshalltown Marshall Iowa Chris Hart Jody Steward 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
2033 2024-02-07 11:38 Anonymous (not verified) 94.188.205.168 JENKINS CONSTRUCTION Proprietorship 315 NORTH MAIN STREET, P.O. BOX 124, ODEBOLT, IA 51458 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-07 DENNIS CHARLES JENKINS dcjmjenkins@yahoo.com ODEBOLT SAC IOWA ROBERT EUGENE BELT JOHN CLARENCE OLERICH Signed (1) The employer does not elect the employers’ liability coverage. DENNIS CHARLES JENKINS dcjmjenkins@yahoo.com SELF ODEBOLT SAC IOWA ROBERT EUGENE BELT JOHN CLARENCE OLERICH Signed
167 2020-05-27 11:51 Anonymous (not verified) 66.188.136.150 Dennis Heinlen Proprietorship 3415 Upland Rd. Lowellville, OH I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-26 Dennis Heinlen kschumacher@tricorinsurance.com Lowellville Mahoning OH Russell Masartis Nancy Wortley Signed (1) The employer does not elect the employers’ liability coverage. Dennis Heinlen kschumacher@tricorinsurance.com Same Lowellville Mahoning OH Russell Masartis Nancy Wortley Signed
1821 2023-08-29 10:11 Anonymous (not verified) 94.188.205.169 Des Moines Smart Solutions LLC Limited Liability Company 1329 56th St., Des Moines, IA 50311 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-29 Denzel Colocho alejandro_colocho@yahoo.com Des Moines Polk Iowa Steve Webb Austin Kelderman Signed (1) The employer does not elect the employers’ liability coverage. Des Moines Smart Solutions LLC alejandro_colocho@yahoo.com Owner Des Moines Polk Iowa Steve Webb Austin Kelderman Signed
1828 2023-09-06 14:43 Anonymous (not verified) 94.188.205.177 Des Moines Smart Solutions LLC. Proprietorship 1329 56th st, Des Moines, IA 50311, United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-06 Denzel Colocho alejandro_colcho@yahoo.com Des Moines, IA Polk Iowa Jordan Nisiewicz Jordan Loyd Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay MO Jordan Loyd Charles Wood Signed
2148 2024-04-15 11:15 Anonymous (not verified) 94.188.207.224 Derek Fetzer Proprietorship 360 250th St, West Branch, IA 52358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-17 Dere W Fetzer kellylanz1967@gmail.com West Branch IA United States Maribelle Lund Carl Lund Signed (1) The employer does not elect the employers’ liability coverage. Derek Fetzer kellylanz1967@gmail.com Self West Branch IA United States Maribelle Lund Carl Lund Signed
1298 2022-09-07 09:58 Anonymous (not verified) 173.29.47.222 Premiere Plastering & Drywall, Inc. Proprietorship 2331 W. 63rd 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. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-09-07 Derek Sherwodd sherwoodpainting@hotmail.com Davenport Scott Iowa Jamie Wardlow Kandra Blumenshein Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Premiere Plastering & Drywall, Inc. premiere_pd_llc@yahoo.com Subcontractor Davenport Scott Iowa Jamie Wardlow Kandra Blumenshein 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
366 2021-01-18 18:32 Anonymous (not verified) 75.162.57.214 Affordable Exteriors, LLC Limited Liability Company 802 east COUNTY LINE RD #57 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-18 Destiny Moses Info@mktdsm.com DES MOINES IA United States Miguel Angel Garcia Ramirez Nelly Bekker Signed (1) The employer does not elect the employers’ liability coverage. Destiny Moses Info@mktdsm.com owner DES MOINES IA United States Miguel Garcia Nellie Bekker 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
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
1620 2023-05-01 08:03 Anonymous (not verified) 94.188.207.228 Devon Willis Proprietorship 401 West 1st Street, Mechanicsville, IA 52306, United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-01 Devon Willis willisbaseball2@gmail.com Mechanicsville, IA Cedar Iowa Jordan Nisiewicz Jordan Loyd Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Missouri Clay Jordan Loyd Robert Snyder Signed
631 2021-09-02 22:46 Anonymous (not verified) 173.23.144.4 Lopez Framing LLC Limited Liability Company 566 walker 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. 2021-09-02 Diana A Garcia Lopez lopezframing0702@gmail.com Des moines Polk Iowa Marlon Lopez Jennifer Reyes Signed (1) The employer does not elect the employers’ liability coverage. Diana A Garcia Lopez lopezframing0702@gmail.com Owner Des moines Polk Iowa Marlon Lopez Jennifer Reyes Signed
1183 2022-07-06 13:43 Anonymous (not verified) 50.82.95.247 2DL Construction, LLC Limited Liability Company 1134 21st Street, Des Moines, IA 50311 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-06 Diego Lopez calihernandez01@icloud.com Des Moines Polk Iowa Ryan Johnson Deanna Yersin Signed (1) The employer does not elect the employers’ liability coverage. Diego Lopez calihernandez01@icloud.com Self Des Moines Polk Iowa Ryan Johnson Deanna Yersin 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
1546 2023-03-29 20:53 Anonymous (not verified) 94.188.205.175 D2 Construction LLC Limited Liability Company 16192 Wendover Ave Madrid, Iowa 50156 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-29 Dillon Devine d2construction22@gmail.com Madrid Dallas Iowa Mark Devine Jodie Gumm Signed (1) The employer does not elect the employers’ liability coverage. Dillon Devine d2construction22@gmail.com Owner Madrid Dallas Iowa Mark Devine Jodie Gumm Signed
2113 2024-03-23 10:21 Anonymous (not verified) 94.188.205.166 D2 Construction Limited Liability Company 16192 wendover ave Madrid Ia 50156 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-23 Dillon Devine d2construction22@gmail.com Madrid Dallas Iowa Chelsey devine Jodie Gumm Signed (1) The employer does not elect the employers’ liability coverage. Dillon devine d2construction22@gmail.com Self Madrid Dallas Iowa Chelsey devine Jodie gumm Signed
467 2021-04-10 12:21 Anonymous (not verified) 24.252.54.168 Dave and Nancy Preucil Inc. Proprietorship 13585 Clearview Lane I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-10 Domenico Zurini II davesspeedwaydz@gmail.com Council Bluffs IA United States Irven Saar II Jeffrey Hanke Signed (1) The employer does not elect the employers’ liability coverage. Barbi Zurini bzurini@gmail.com Wife Council Bluffs IA United States Irven Saar II Jeffrey Hanke Signed
2109 2024-03-21 11:15 Anonymous (not verified) 94.188.205.169 Panameno Stone Proprietorship 3701 SE 18th Ct. Des Moines, IA 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-21 Domingo Panameno albertpana08@gmail.com Des Moines Polk Iowa Drakkar Rapaich Fabi Palomares Signed (1) The employer does not elect the employers’ liability coverage. Domingo Panameno albertpana08@gmail.com Self Des Moines Polk Iowa Drakkar Rapaich Fabi Palomares Signed
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
2011 2024-01-31 07:01 Anonymous (not verified) 94.188.205.166 Goede Mechanical Limited Liability Company 1607 10th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-31 Don Goede goedemechanical@gmail.com Harlan Shelby Iowa Dylan Goede Kallie Goede Signed (1) The employer does not elect the employers’ liability coverage. Don Goede goedemechanical@gmail.com Owner Harlan Shelby Iowa Dylan Goede Kallie Goede Signed
415 2021-03-01 17:06 Anonymous (not verified) 208.126.61.78 Fryes Tree Service Proprietorship P.O. Box 244 Webster City, IA 50595 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-01 Don Johnson fts.don@gmail.com Webster City Hamilton IA Jenna Shaw Tim Turner Signed (1) The employer does not elect the employers’ liability coverage. Don Johnson fts.don@gmail.com Owner Webster City Hamilton IA Jenna shaw Tim Turner 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
237 2020-08-18 19:01 Anonymous (not verified) 174.125.150.45 Wdflyers llc Limited Liability Company 453 hwy 1183 Simmesport la 71369 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-25 Donald Anderson sugarscoot@yahoo.com Simmesport Avoyelles Louisiana kolter coco wendy coco Signed (1) The employer does not elect the employers’ liability coverage. Donald Anderson sugarscoot@yahoo.com self Simmesport Avoyelles Louisiana kolter coco wendy coco 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
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
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
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
1429 2023-01-25 13:43 Anonymous (not verified) 136.35.255.41 J&D Renovations Proprietorship 114 2nd St. Carbon Cliff, IL 61239 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-25 Donald Lane jdrenovations309@gmail.com Carbon Cliff, IL Rock Island County Illinois Jordan Nisiewicz Cody Dunbar Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay Missouri Jordan Loyd Cody Dubar Signed
1090 2022-05-06 08:08 Anonymous (not verified) 65.111.39.23 Farr TRucking Inc Proprietorship 2206 E Locust Ln, Table Grove, IL 61482 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-06 Donald Paul Farr howthewestisdone@gmail.com Table Grove Fulton Illinois Tamra Stambaugh Keith Allard Signed (1) The employer does not elect the employers’ liability coverage. DeYonne L Farr howthewestisdone@gmail.com Secretary Table Grove Fulton Illinois Tamra Stambaugh Keith Allard Signed
1334 2022-10-14 08:28 Anonymous (not verified) 67.212.98.135 Verbraken's New Look Painting & Decorating Proprietorship 147 Barryington Dr. Waterloo, IA 50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-14 Donald Verbraken verbptg@aol.com Waterloo Black Hawk Iowa Cody Stoppel Rusty Donnelly Signed (1) The employer does not elect the employers’ liability coverage. Donald Verbraken verbptg@aol.com Owner Waterloo Black Hawk Iowa Cody Stoppel Rusty Donnelly Signed
1168 2022-06-23 12:57 Anonymous (not verified) 74.84.106.106 dora valadez Proprietorship 1244 e 32 nd 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. 2022-06-23 dora valadez towens@smartind.com Des Moines Polk Iowa Tina Owens Kim Owens Signed (1) The employer does not elect the employers’ liability coverage. dora valadez towens@smartind.com self Des Moines Polk Iowa Tina Owens Kim Owens 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
621 2021-08-27 16:11 Anonymous (not verified) 71.39.227.238 DOUG WEISS DBA DIRTWORKS Proprietorship 23966 MIDLAND TRAIL, DALLAS CENTER, IA 50063 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-27 DOUG WEISS EWEISSN03.EW@GMAIL.COM DALLAS CENTER DALLAS IOWA DON RICHARDSON ABBEY LUELLEN Signed (1) The employer does not elect the employers’ liability coverage. DOUG WEISS EWEISSN03.EW@GMAIL.COM SELF DALLAS CENTER DALLAS IOWA DON RICHARDSON ABBEY LUELLEN Signed
779 2021-12-06 10:43 Anonymous (not verified) 172.83.21.144 Munn Enterprises LLC Limited Liability Company 118 14th Avenue South I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-06 Douglas A Munn munnent1328@gmail.com Clear lake IA IA Troy Thomas Munn Marjorie Marie Munn Signed (1) The employer does not elect the employers’ liability coverage. Troy Munn Troy@munnentllc.com Owner Clear Lake Cerro Gordo Iowa Troy Thomas Munn Marjorie Marie Munn Signed
795 2021-12-15 07:47 Anonymous (not verified) 173.22.84.26 LAMPE APPLIANCE SERVICE, Inc Proprietorship 210 29TH ST 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. 2021-12-15 Douglas James Lampe lampeappliance@gmail.com CEDAR RAPIDS IA IA John Kenneth Lampe Kenneth Roman Lampe Signed (1) The employer does not elect the employers’ liability coverage. Douglas James Lampe lampeappliance@gmail.com Vice President Cedar Rapids Linn Iowa John Kenneth Lampe Kenneth Roman Lampe Signed
1290 2022-09-01 15:29 Anonymous (not verified) 198.14.221.176 DR. WAYNE HAIDSIAK ii and Dr. Junior Hensley DBA Tri County Veterinary Service Partnership 101 170TH ST CLEARFIELD IA 50840 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-01 Dr. Wayne Haidsiak II insurance@ringgoldins.com Lenox Taylor IA Amy Ford Deb Davenport Signed (1) The employer does not elect the employers’ liability coverage. Dr. J.D. Hensley insurance@ringgoldins.com Partner Cleafield Taylor IA Amy Ford Deb Davenport Signed
1027 2022-04-01 16:00 Anonymous (not verified) 75.162.62.199 Modern Carpentry Concepts Limited Liability Company 2012 Ammann Dr. Adel, IA 50003 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-01 Drew Hoffman d.s.hoffman14@gmail.com Adel Dallas Iowa Jessica Hoffman Warren Holder Signed (1) The employer does not elect the employers’ liability coverage. Drew Hoffman d.s.hoffman14@gmail.com Same Person Adel Dallas Iowa Jessica Hoffman Warren Holder 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
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
274 2020-10-06 13:18 Anonymous (not verified) 174.250.65.147 Ddp construction Proprietorship 1923 63rd st. Urbandale , ia 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-06 Dustin a perry perrythedustin@gmail.com Urbandale Polk Iowa Luke jackson Loud jackson Signed (1) The employer does not elect the employers’ liability coverage. Dustin perry perrythedustin@gmail.com Owner Urbandale Polk Iowa Luke jackson Loyd jackson Signed
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
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
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
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
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
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
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
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
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
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
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
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
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
2157 2024-04-17 11:16 Anonymous (not verified) 94.188.205.168 LAKESIDE DETAILING LLC Limited Liability Company 249 EMERALD MEADOWS DR, ARNOLDS PARK, IA 51331 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-17 DYLAN MCHUGH 19DMCHUGH@GMAIL.COM ARNOLDS PARK DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. DYLAN MCHUGH 19DMCHUGH@GMAIL.COM SELF ARNOLDS PARK DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH 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
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
1075 2022-04-28 07:53 Anonymous (not verified) 172.58.160.241 E & J Roofing LLC Limited Liability Company 5008 SE 5th Street Des Moines Iowa 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-28 E & J Roofing LLC janeylli2006@hotmail.com Des Moines United States Iowa Javier Solís Saldaña Arhely S. Saldaña Signed (1) The employer does not elect the employers’ liability coverage. E & J Roofing LLC janeylli2006@hotmail.com Owner Des Moines Polk Iowa Javier Solís Saldaña Arhely S. Saldaña Signed
1477 2023-02-23 11:45 Anonymous (not verified) 94.188.205.166 Earl Woods DBA Solar Solutions Proprietorship 1328 42nd 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. 2023-02-23 Earl Woods solarsolutions_1@msn.com Des Moines Polk Iowa Terrie Woods Tracy Day Signed (1) The employer does not elect the employers’ liability coverage. Earl Woods solarsolutions_1@msn.com wife Des Moines Polk IA Terrie Woods Tracy Day Signed
195 2020-06-29 08:55 Anonymous (not verified) 107.77.173.23 E.S.T. Construction LLC Limited Liability Company 2412 E 16th st Des Moines, IA 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-29 Eber Saul Torres estorres48@gmail.com Des Moines Polk Iowa Hailey Galdames Luna Abel Mejia Signed (1) The employer does not elect the employers’ liability coverage. Eber Saul Torres estorres48@gmail.com Self Des Moines Polk IOWA Hailey Galdames Luna Abel Mejia Signed
1559 2023-04-07 11:43 Anonymous (not verified) 94.188.205.177 Art Deco Tile and Stone Limited Liability Company 4615 94th Pl Urbandale, IA 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-07 Edin Musinovic edin@artdecotileandstone.com Urbandale Polk Iowa Rick Wyant Todd Wyant Signed (1) The employer does not elect the employers’ liability coverage. Edin Musinovic edin@artdecotileandstone.com Self Urbandale Polk Iowa Rick Wyant Todd Wyant Signed
268 2020-09-22 09:21 Anonymous (not verified) 174.217.16.178 Ayala Brothers Painting & Drywall Proprietorship 25089 H Ave Adel IA 50003 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-22 Edson Ayala Arizaga Ayalabrospainting@gmail.com Adel Dallas Iowa Abel Ayala Laura Orozco Signed (1) The employer does not elect the employers’ liability coverage. Edson Ayala Arizaga Edsonayala.12@gmail.com Owner Adel Dallas Iowa Abel Ayala Laura Orozco Signed
388 2021-02-10 11:48 Anonymous (not verified) 97.125.123.32 Pro Bull Painting LLC Limited Liability Company 1204 sampson st Des Moines IA 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-10 Eduardo Garcia Becerril probullpainting1@gmail.com Des Moines Polk Iowa Juan Carlos Garcia Rigoberto Garcia Signed (1) The employer does not elect the employers’ liability coverage. Eduardo Garcia Probullpainting1@gmail.com Owner Des moines Polk Iowa Juan Carlos Garcia Rigoberto Garcia Signed
97 2020-03-21 12:05 Anonymous (not verified) 173.22.82.137 JHK Construction LLC Limited Liability Company 6203 Casey Court NE Cedar Rapids, IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-21 Edward Charles Loehr jhkconstruction10@gmail.com Cedar Rapids Linn County Iowa Brandon Peters Mandy Mason Signed (1) The employer does not elect the employers’ liability coverage. Edward Charles Loehr jhkconstruction10@gmail.com Owner 6203 Casey Court NE Linn County Iowa Brandon Peters Mandy Mason Signed
875 2022-01-31 11:00 Anonymous (not verified) 173.31.102.93 Jhk Construction LLC Limited Liability Company 6203 Casey Ct NE cedar Rapids Iowa 52411 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-31 Edward Charles Loehr jhkcostruction10@gmail.com Cedar Rapids Linn Iowa Leanne M Loehr Autumn G Loehr Signed (1) The employer does not elect the employers’ liability coverage. Jhk Construction LLC jhkconstruction10@gmail.com Owner Cedar Rapids Linn Iowa Leanne M Loehr Autumn G Loehr 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
1435 2023-01-31 14:33 Anonymous (not verified) 174.215.242.112 Premier builders Proprietorship 1821 East Ridgeway I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-31 Edward Koch etkdbq@aol.com Waterloo IA United States Glenda mclarty Coen Koch Signed (1) The employer does not elect the employers’ liability coverage. Edward Koch etkdbq@aol.com Owner Waterloo IA United States Glenda Mclarty Coen Koch Signed
1436 2023-02-01 11:53 Anonymous (not verified) 174.215.242.112 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. 2023-02-01 Edward Koch etkdbq@aol.com Waterloo IA United States Glenda mclarty Coen Koch Signed (1) The employer does not elect the employers’ liability coverage. Brian yurko byurko@leafhome.com Recruiter Hudson Summit Ohio Brian Mako Matt kaulig Signed
1437 2023-02-01 15:42 Anonymous (not verified) 174.215.242.112 Safe step walk in tub of Minnesota Limited Liability Company 7300 Washington Ave S. Eden prairie, MN 55344 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-01 Edward Koch etkdbq@aol.com Waterloo IA United States Glenda mclarty Coen Koch Signed (1) The employer does not elect the employers’ liability coverage. James alley JAlley@safesteptub.com Vice president of production Eden prairie Hennepin MN Brent Jarvis Bruce illies 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
1609 2023-04-26 11:58 Anonymous (not verified) 94.188.205.168 edwin gonzalez Proprietorship 115 e ayers st osceola ia 50213 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-26 edwin gonzalez lrestrada83@gmail.com osceola Clark ia Sheanah Wright Derek Mullins Signed (1) The employer does not elect the employers’ liability coverage. edwin gonzalez lrestrada83@gmail.com owner osceola clarke ia Sheanah Wright Derek Mullins Signed
1671 2023-06-01 11:17 Anonymous (not verified) 94.188.205.166 Edwin Kime Proprietorship 2920 Windsor av sumner iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-01 edwin kime edwinkime01@gmail.com sumner ia United States Lori Ann kime Kiley Nicole kime Signed (1) The employer does not elect the employers’ liability coverage. edwin kime edwinkime01@gmail.com Same sumner ia United States Lori Ann kime Kiley nicolevkime Signed
1069 2022-04-26 08:39 Anonymous (not verified) 174.198.72.171 GR Roofing Proprietorship 802 E County Line Rd Lot 137, 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. 2022-04-26 Eleazar Guzman-Rios emmanuelgscop.1425@gmail.com Des Moines Polk Iowa Manny Socop Julio Andrew Signed (1) The employer does not elect the employers’ liability coverage. Eleazar Guzman-Rios emmanuelgscop.1425@gmail.com Owner Des Moines Polk Iowa Manny Socop Julio Andrews Signed
1841 2023-09-14 13:52 Anonymous (not verified) 94.188.207.225 Double M Construction LLC Limited Liability Company 3886 Diamond Rd, Elgin, IA 52141 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-16 Eli Miller elimiller@gmail.com Iowa Fayette Iowa Julie Schick Kelly Matt Signed (1) The employer does not elect the employers’ liability coverage. Eli Miller elimiller@gmail.com self Elgin Fayette Iowa Julie Schick Kelly Matt Signed
216 2020-07-27 13:47 Anonymous (not verified) 173.28.28.57 Main Street Printing & Design, LLC Limited Liability Company 706 3rd Avenue, Parkersburg IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-09 Eliesa Thomas cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Eliesa Thomas cmins_re@mchsi.com Self Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed
1521 2023-03-16 14:26 Anonymous (not verified) 94.188.207.229 Mmk electric Partnership 4515 84th st Urbandale 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. 2023-03-16 Elijah dale kain mmk.iowa@gmail.com West Des moines Polk Iowa Travis Lee miller Marshall Logan McKay Signed (1) The employer does not elect the employers’ liability coverage. Travis Lee miller mmk.iowa@gmail.com Owner Urbandale Polk Iowa Travis Lee miller Marshall Logan mckay Signed
600 2021-08-12 11:04 Anonymous (not verified) 173.19.179.111 ELIJAH HIX Proprietorship PO BOX 465 MILFORD IA 51351 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-11 ELIJAH HIX HIXSKIDOO800@GMAIL.COM MILFORD DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. ELIJAH HIX HIXSKIDOO800@GMAIL.COM SELF MILFORD DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
1329 2022-10-10 10:55 Anonymous (not verified) 173.25.222.69 Eli's Limited Liability Company 931 S Van Buren St Iowa City, Iowa 52240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-10 Elijah Ortiz eortiz15@gmail.com Iowa City Johnson Iowa Erica Mason Bryan Horrell Signed (1) The employer does not elect the employers’ liability coverage. Elijah Ortiz eortiz15@gmail.com Proprietor Iowa City Johnson Iowa Erica Mason Bryan Horrell 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
1267 2022-08-17 14:11 Anonymous (not verified) 174.192.75.162 Elijah wyant Proprietorship 708 1/2 w 3rd st davenport ia 52802 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-17 Elijah wyant Aidenwyant@gmail.com Davenport Scott Iowa Jake laxton Courtney sanders Signed (1) The employer does not elect the employers’ liability coverage. Elijah wyant Aidenwyant@gmail.com Self Davenport Scott Iowa Jake laxton Courtney sanders Signed
914 2022-02-15 10:22 Anonymous (not verified) 206.72.12.83 Custom Windows Plus Limited Liability Company 1623 Rose Avenue Allendorf Iowa 51354 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-15 Elijah Zevenbergen elijah.zevenbergen@gmail.com Allendorf United States IA Andrea Johnson Brennan Krogman Signed (1) The employer does not elect the employers’ liability coverage. Elijah Zevenbergen elijah.zevenbergen@gmail.com Owner Allendorf United States IA Andrea Johnson Brennan Krogman Signed
1512 2023-03-10 09:44 Anonymous (not verified) 94.188.205.169 eliseo isai Proprietorship 5301 SE 24th St Des Moines, IA 50320 United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-08 eliseo isai carranza perez Misaelballeza40@gmail.com desmoines polk iowa Julio Nolvela giovanni nolvela Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. eliseo isai carranza perez Misaelballeza40@gmail.com self desmoines polk iowa Julio Nolvela giovanni nolvela Signed
193 2020-06-24 11:13 Anonymous (not verified) 173.28.196.82 Gray Nation LLC DBA Gray Goat Tattoo Limited Liability Company 116 N 1st Street West Branch, Iowa 52358-9663 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2020-06-24 Elizabeth Gray beth.gray516@gmail.com West Branch Cedar Iowa Luis Ordenana Don Naugthon Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Elizabeth Gray beth.gray516@gmail.com LLC Member West Branch Cedar Iowa Luis Ordenana Don Naughton Signed
899 2022-02-05 13:35 Anonymous (not verified) 67.3.142.168 Hart Holland LLC Limited Liability Company 526 N 13th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-05 Elizabeth Holland ehollanddvm@gmail.com Adel IA IA Jon Hart Mary Hart Signed (1) The employer does not elect the employers’ liability coverage. Elizabeth Holland ehollanddvm@gmail.com self Adel IA IA Jon Hart Mary Hart Signed
900 2022-02-05 13:36 Anonymous (not verified) 67.3.142.168 Iconic Properties LLC Limited Liability Company 526 N 13th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-05 Elizabeth Holland ehollanddvm@gmail.com Adel IA IA Jon Hart Mary Hart Signed (1) The employer does not elect the employers’ liability coverage. Elizabeth Holland ehollanddvm@gmail.com self Adel IA IA Jon Hart Mary Hart Signed
1316 2022-09-21 14:49 Anonymous (not verified) 184.81.198.17 Ellen Faye Stevenson Proprietorship 201 Stephans st. Tiffin, Iowa 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. 2022-09-21 Ellen Faye Stevenson nelle@southslope.net Tiffin Johnson Iowa Catherine Louise Nelson Joseph Roger Titone Signed (1) The employer does not elect the employers’ liability coverage. Ellen Faye Stevenson nelle@southslope.net myself Tiffin Johnson Iowa Catherine Louise Nelson Joseph Roger Titone Signed
622 2021-08-27 16:12 Anonymous (not verified) 71.39.227.238 DOUG AND ELLEN WEISS DBA DIRTWORKS Proprietorship 23966 MIDLAND TRAIL, DALLAS CENTER, IA 50063 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-27 ELLEN WEISS EWEISSN03.EW@GMAIL.COM DALLAS CENTER DALLAS IOWA DON RICHARDSON ABBEY LUELLEN Signed (1) The employer does not elect the employers’ liability coverage. ELLEN WEISS EWISSN03.EW@GMAIL.COM SELF DALLAS CENTER DALLAS IOWA DON RICHARDSON ABBEY LUELLEN Signed
986 2022-03-18 16:46 Anonymous (not verified) 174.213.145.90 Gonzalez Contractors LLC. Limited Liability Company 150 NE 41st St Unit 109 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-18 Elmer Gonzalez gonzalez922014@icloud.com Ankeny Polk IA Kassandra Gonzalez Jesus Gonaalez Signed (1) The employer does not elect the employers’ liability coverage. Elmer Gonzalez gonzalez922014@icloud.com Owner Ankeny Polk IA Kassandra Gonzalez Jesus Gonzalez Signed
1002 2022-03-23 13:04 Anonymous (not verified) 174.255.6.78 Gonzalez Contractors LLC. Limited Liability Company 240 NE 41st St unit 203 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-23 Elmer Gonzalez gonzalez922014@icloud.com Ankeny Polk IA Kassandra Gonzalez Jesus Gonzalez Signed (1) The employer does not elect the employers’ liability coverage. Elmer Gonzalez gonzalez922014@icloud.com Owner Ankeny Polk IA Kassandra Gonzalez Jesus Gonzalez Signed
2088 2024-03-12 10:44 Anonymous (not verified) 94.188.207.226 Elmer Henry Vicente Lopez Proprietorship 1602 Court St Apt 2 Sioux City, IA 51105 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-01 Elmer Henry Vicente Lopez vicenteelmer33@gmail.com Sioux City Woodbury Iowa Adrian Dominguez Ronald Halverson Signed (1) The employer does not elect the employers’ liability coverage. Ron Halverson ron@sppinsurance.com independent contractor Cherokee Cherokee IA Elmer Henry Vicente Lopez Ronald Halverson Signed
842 2022-01-17 16:29 Anonymous (not verified) 172.58.87.164 The Green Boys Limited Liability Company 55 Southeast Windfield Parkway I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-17 Emilio Belismelis emiliobelismelis87@gmail.com Waukee IA United States Lorena Belismelis Lorena Belismelis Signed (1) The employer does not elect the employers’ liability coverage. The Green Boys emiliobelismelis87@gmail.com Owner Waukee IA United States Emilo Belismelis Maria Belismelis Signed
1139 2022-06-02 08:49 Anonymous (not verified) 174.198.67.34 Gentry Hardware Incorporated Partnership 308 5th Street; Rockwell City, IA 50579 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-02 Emily Gentry emilygentry1127@gmail.com Rockwell City Calhoun IA Ben Rand Karie Knouf Signed (1) The employer does not elect the employers’ liability coverage. Emily Gentry emilygentry1127@gmail.com Owner Rockwell City Calhoun IA Ben Rand Karie Knouf Signed
890 2022-02-03 15:11 Anonymous (not verified) 173.23.180.117 E.A. Electric LLC Limited Liability Company 1065 South Hill Dr, Waterloo, IA 50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-03 Emin Alibegic emin.alibegic@yahoo.com Waterloo Black Hawk Iowa Nickole Pry Christine Willis Signed (1) The employer does not elect the employers’ liability coverage. Emin Alibegic emin.alibegic@yahoo.com Same Person Waterloo Black Hawk Iowa Nickole Pry Christine Willis Signed
1932 2023-12-01 20:02 Anonymous (not verified) 94.188.205.168 Wasabi Johnston LLC Limited Liability Company 2965 SE Timberline dr, Waukee, IA, 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-01 Enjin zheng jimmyzheng1573@gmail.com Waukee Dallas Iowa Jenna Yu Wen Zheng Signed (1) The employer does not elect the employers’ liability coverage. Enjin zheng jimmyzheng1573@gmail.com Owner Waukee Dallas Iowa Jenna Yu Wen Zheng Signed
1986 2024-01-16 12:18 Anonymous (not verified) 94.188.207.229 Wasabi Urbandale LLC Limited Liability Company 2965 Se Timberline dr , Waukee , Iowa 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-16 Enjinzheng jimmyzheng1573@gmail.com Waukee Dallas Iowa Jie Li Yingnazheng Signed (1) The employer does not elect the employers’ liability coverage. Enjin zheng jimmyzheng1573@gmail.com Owner Waukee Dallas Iowa Jie Li Yingna zheng Signed
554 2021-07-01 15:54 Anonymous (not verified) 75.162.212.130 Avila Gutters Inc Proprietorship 5901 sw 5th 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. 2021-06-24 Enrique Avila enrique86avila@gmail.com Des moines polk iowa Yolanda Mendoza Lilliana Sanchez Signed (1) The employer does not elect the employers’ liability coverage. Enrique Avila enrique86Avila@gmail.com owner des moines polk iowa yolanda mendoza liliana sanchez Signed
253 2020-09-09 12:27 Anonymous (not verified) 173.18.16.129 H E Drywall INC Proprietorship 200 E Lally St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-09 Eriberto Castro hedrywall82@gmail.com Des Moines Polk Iowa Lesa Reeves Jake Hibbert Signed (1) The employer does not elect the employers’ liability coverage. eriberto castro hedrywall82@gmail.com owner Des Moines Polk Iowa Lesa Reeves Jake Hibbert Signed
1955 2023-12-14 09:19 Anonymous (not verified) 94.188.207.229 Protouch snow&lawn llc Limited Liability Company 4015 sager ave waterloo I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-14 Eric brown brown39s@yhoo.com Waterloo United States Iowa Joe brown Emily brown Signed (1) The employer does not elect the employers’ liability coverage. Eric brown brown39s@yahoo.com Self Waterloo United States Iowa Emily brown Joe brown Signed
282 2020-10-21 07:00 Anonymous (not verified) 98.16.114.26 Fine Cut Lawn Service, LLC Limited Liability Partnership 110 E Street, SW. P.O. Box 835 Melcher, IA. 50163 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-19 Eric E Benz eric@finecutwaterscapes.com Melcher Marion IA Angelia Warner Allen Smith Signed (1) The employer does not elect the employers’ liability coverage. Eric Eugene Benz eric@finecutlawn.com same person Melcher Marion IA Angela Warner Allen Smith Signed
540 2021-06-08 21:40 Anonymous (not verified) 50.83.39.243 Brightland Appraisal Group Limited Liability Company 1348 Rolling Glen Dr. Marion IA 52302 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-08 Eric Lamp eric.lamp@brightlandappraisal.com Marion Linn Iowa Sarah Lamp Linda Lamp Signed (1) The employer does not elect the employers’ liability coverage. Eric Allen Lamp eric.lamp@brightlandappraisal.com Self Marion Linn Iowa Sarah Lamp Linda Lamp Signed
70 2020-02-19 19:30 Anonymous (not verified) 173.25.39.58 Central Iowa Portable Welding Limited Liability Company 708 S Main St. Woodward Ia, 50276 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-19 Eric Lendt Eric@weldiowa.com Woodward America IA Chris Lendt Central Iowa Portable Welding Signed (1) The employer does not elect the employers’ liability coverage. Central Iowa Portable Welding Eric@weldiowa.com Himself woodward American IA Central Iowa Portable Welding Central Iowa Portable Welding Signed
1000 2022-03-23 10:24 Anonymous (not verified) 75.162.12.87 Eric Louvan Proprietorship 2840 104th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-23 Eric Louvan elouvan@phillipssstafford.com Ankeny Polk Iowa Brandon Johnson Ann Louvan Signed (1) The employer does not elect the employers’ liability coverage. Brad Phillips bphillips@phillipsstafford.com Employee Urbandale Polk IA Eric Louvan Luke Vanroekel Signed
37 2020-01-16 15:26 Anonymous (not verified) 173.24.236.134 Eric Krueger Proprietorship 406 NE Oak Dr. Ankeny, IA 50021 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-16 Eric Lucas Krueger erickrugs@gmail.com Ankeny Polk Iowa Emily Marie Krueger Roberty William Krueger Signed (1) The employer does not elect the employers’ liability coverage. Eric Krueger erickrugs@gmail.com self Ankeny Polk Iowa Emily Marie Krueger Robert William Krueger Signed
351 2021-01-06 16:20 Anonymous (not verified) 173.25.23.170 Eric Krueger Proprietorship 406 NE Oak Dr. Ankeny, IA 50021 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-07 Eric Lucas Krueger erickrugs@gmail.com Ankeny Polk Iowa Emily Marie Krueger Robert William Krueger Signed (1) The employer does not elect the employers’ liability coverage. Eric Lucas Krueger erickrugs@gmail.com self Ankeny Polk Iowa Emily Marie Krueger Robert William Krueger Signed
928 2022-02-17 19:46 Anonymous (not verified) 208.83.187.211 Eric Marsh Trucking LLC Limited Liability Company 1029 Davis Ave Westbrook MN 56183 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-17 Eric Marsh emt78@yahoo.com Westbrook Cottonwood MN Dustin Krick Sam Hansen Signed (1) The employer does not elect the employers’ liability coverage. Eric Marsh emt78@yahoo.com Self Westbrook Cottonwood MN Dustin Krick Sam Hansen Signed
1577 2023-04-17 09:58 Anonymous (not verified) 94.188.205.167 Four Leaf LLC Limited Liability Company 11150 NE 72nd St 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. 2023-04-17 Eric O'Shea Fourleaf2021@gmail.com Bondurant IA United States Lucas Gray Curt Decker Signed (1) The employer does not elect the employers’ liability coverage. Eric Michael O'Shea Fourleaf2021@gmail.com Owner Bondurant IA United States Lucas Gray Curt Decker Signed
1214 2022-07-20 09:51 Anonymous (not verified) 173.23.180.117 Eric Morse Proprietorship 1610 Hawthorne Ave, 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. 2022-05-09 Eric Richard Morse ericmorse82@gmail.com Waterloo Black Hawk Iowa Christine Diane Willis (notary) Steve Sprague Signed (1) The employer does not elect the employers’ liability coverage. Eric Morse ericmorse82@gmail.com Self Waterloo Black Hawk Iowa Christine Diane Willis (notary) Steven Sprague Signed
318 2020-11-16 15:06 Anonymous (not verified) 50.82.130.211 Boulder Woodworks, LLC Limited Liability Company 3011 Boulder Drive, Cedar Falls IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-28 Eric Simmons cmins_re@mchsi.com Cedar Falls Black Hawk Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Eric Simmons cmins_re@mchsi.com Self Cedar Falls Black Hawk Iowa Chad Campbell Roxanne Kolder Signed
411 2021-02-22 15:58 Anonymous (not verified) 173.24.190.134 The Willow Tree Garden Center Limited Liability Company 2103 19rh Street, Emmetsburg IA 50536 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-22 Erica Janssen mrjanz13@gmail.com Emmetsburg Palo Alto Iowa Marilee Lace Candie Clark Signed (1) The employer does not elect the employers’ liability coverage. Erica Janssen mrjanz13@gmail.com Member of LLC Emmetsburg Palo Alto Iowa Marilee Lace Candie Clark Signed
2192 2024-04-29 13:15 Anonymous (not verified) 94.188.205.166 ElmStreet Apothecary Limited Liability Company 320 W Kimberly Road #227 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-29 Erica McGee esalsbury07@gmail.com Bettendorf Scott Ia Jennifer West Julie Francis Signed (1) The employer does not elect the employers’ liability coverage. Erica McGee esalsbury07@gmail.com Self Bettendorf Scott Ia Jennifer West Julie Francis Signed
484 2021-04-16 10:58 Anonymous (not verified) 66.188.136.150 Erick Hodges Proprietorship 3039 Magnolia Dr. Bettendorf, IA 52722 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-16 Erick Hodges kschumacher@tricorinsurance.com Bettendorf Scott IA Jordan Bass Russell Masartis Signed (1) The employer does not elect the employers’ liability coverage. Erick Hodges kschumacher@tricorinsurance.com Same Bettendorf Scott IA Jordan Bass Russell Masartis Signed
1708 2023-06-25 15:10 Anonymous (not verified) 94.188.207.228 Lopez concrete Limited Liability Company 2009 otley ave perry Ia 50220 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-25 Erick Lopez lopez1concrete@gmail.com Perry Dallas IA Ever tobar. Elba alejandro Signed (1) The employer does not elect the employers’ liability coverage. Erick lopez lopez1concreto@gmail.com Owner Perry Dallas IA Ever tobar Elba alejandro 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
400 2021-02-15 14:44 Anonymous (not verified) 192.30.185.142 Certified Radon Mitigation Proprietorship 4304 Garretson Ave, Sioux City, IA 51106 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-15 Erik Poss rn222@outlook.com Sioux City Woodbury IA Katie Jenks Nate Blaeser Signed (1) The employer does not elect the employers’ liability coverage. Erik Poss rn222@outlook.com Owner Sioux City Woodbury IA Katie Jenks Nate Blaeser Signed
1418 2023-01-11 10:44 Anonymous (not verified) 173.23.144.232 precision edge llc Limited Liability Company 101 belmont st milo iowa 50116 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-10 erik reha precisionedgecompanies@gmail.com milo warren iowa bruce wilson jordan rhode Signed (1) The employer does not elect the employers’ liability coverage. n/a precisionedgecompanies@gmail.com n/a n/a n/a n/a bruce wilson jordan rhode Signed
1858 2023-10-03 13:29 Anonymous (not verified) 94.188.207.223 Quad city drywall Solutions LLC Limited Liability Company 5804 n thornwood ave Davenport iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-03 Erivan Emmanuel Montalvo Delcompare montalvobills6@gmail.com Davenport Scott Iowa Natalia Ann Montalvo Juan Portela Signed (1) The employer does not elect the employers’ liability coverage. Erivan Emmanuel Montalvo Delcompare montalvobills6@gmail.com Owner Davenport Scott Iowa Natalia Montalvo Juan Portela Signed
2046 2024-02-15 11:29 Anonymous (not verified) 94.188.205.175 Ervin Cabrera Mendez Proprietorship 4822 Meadowlark Lane, Sioux City, Iowa 51106 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-01 Ervin Cabrera Mendez ervincabrera89@gmail.com Sioux City Woodbury Iowa Kyle Buum David Jacobs Signed (1) The employer does not elect the employers’ liability coverage. Ervin Cabrera Mendez ervincabrera89@gmail.com Owner Sioux City Woodbury Iowa Kyle Buum David Jacobs Signed
1769 2023-07-31 11:23 Anonymous (not verified) 94.188.207.228 PSI LLC Limited Liability Company 2765 N Center Point Rd I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-31 Esteici Reyes stacy0979@gmail.com Cedar Rapids Linn IA Jeffrey Ventura Eduardo Contreras Signed (1) The employer does not elect the employers’ liability coverage. Esteici Reyes stacy0979@gmail.com Owner Cedar Rapids Linn IA Jeffrey Ventura Eduardo Contreras Signed
2153 2024-04-15 21:59 Anonymous (not verified) 94.188.205.167 Ethan M Hoffman Proprietorship 1442 N. County RD 800, Hamilton, IL 62341 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-07 Ethan M Hoffman kellylanz1967@gmail.com Hamilton IL United States Gay Hoffman Debra Kelley Signed (1) The employer does not elect the employers’ liability coverage. Ethan M Hoffman kellylanz1967@gmail.com Self Hamilton IL United States Gay Hoffman Debra Kelley Signed
803 2021-12-16 21:47 Anonymous (not verified) 98.21.205.195 Kustom Home Improvements Proprietorship 400 Davidson St New Virginia Iowa 50210 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-16 Ethan Willett kustomhomeimprovements.dk@gmail.com Osceola Clarke Iowa Cindy Sue Gyles Shantell Christine Rice Signed (1) The employer does not elect the employers’ liability coverage. David Jack Kimmel kustomhomeimprovements.dk@gmail.com Self New Virginia Warren Iowa Cindy Sue Gyles Shantell Christine Rice Signed
194 2020-06-24 15:24 Anonymous (not verified) 173.16.140.254 Eugene Behle Proprietorship 3134 6th Ave Des Moines IA 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-24 Eugene Behle III Bub4bme@gmail.com Des Moines Polk Iowa Kelly Coluzzi Mitch Coluzzi Signed (1) The employer does not elect the employers’ liability coverage. Eugene Behle III Bub4bme@gmail.com Self Des Moines POLK Iowa Kelly Coluzzi Mitch Coluzzi Signed
1364 2022-11-09 09:57 Anonymous (not verified) 50.80.120.38 Egl Enterprises, Inc. Proprietorship 314 2ND AVE NW I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-09 EUGENE G LARUE egl.enterprises.inc@gmail.com HAMPTON IA United States stephanie hofer aryel laRue Signed (1) The employer does not elect the employers’ liability coverage. EUGENE G LARUE egl.enterprises.inc@gmail.com self HAMPTON IA United States stephanie hofer aryel laRue Signed
1114 2022-05-17 15:30 Anonymous (not verified) 67.212.117.198 Busta Painting Limited Liability Company 610 W 26th st #1 Cedar Falls, IA 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-16 Evan Busta bustapainting@gmail.com Cedar Falls IA United States Tanner Heikens Garrett Burrack Signed (1) The employer does not elect the employers’ liability coverage. Evan Busta bustapainting@gmail.com Self Employeed Cedar Falls IA United States Tanner Heikens Garrett Burrack Signed
1691 2023-06-14 19:20 Anonymous (not verified) 94.188.205.174 Amazing Painting LLC Limited Liability Company 1301 Boyd Street, Des Moines, IA 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-14 Evan Michael Regenwether Evan@amazingpaintingia.com Des Moines Polk Iowa Austin Matthew Regenwether Abby Marie Regenwether Signed (1) The employer does not elect the employers’ liability coverage. Evan Michael Regenwether evan@amaingpaintingia.com Owner Des Moines Polk Iowa Austin Matthew Regenwether Abby Regenwether Signed
2042 2024-02-12 13:07 Anonymous (not verified) 94.188.205.175 Evelyn R Ventura Terrazas Proprietorship 524 Terrence I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-12 Evelyn R Ventura Terrazas evelynterrazas@gmail.com Storm Lake Buena vista IA Juan García Oropeza Karen Rodríguez Pantoja Signed (1) The employer does not elect the employers’ liability coverage. Evelyn R Ventura Terrazas evelynterrazas@gmail.com Proprietorship Storm Lake Buena vista IA Juan Garcia Oropeza Karen Rodríguez Pantoja Signed
645 2021-09-18 09:47 Anonymous (not verified) 208.68.114.238 CHL Roofing & Siding Inc Proprietorship 509 1/2 E A St, West Liberty, IA 52776 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-18 Fabian Galvan Rodriguez fgalvanglez14@gmail.com West Liberty Muscatine Iowa Karina A Beltran Nereida Velez Signed (1) The employer does not elect the employers’ liability coverage. Fabian Galvan Rodriguez fgalvanglez14@gmail.com Self West Liberty Muscatine Iowa Karina A Beltran Nereida Velez Signed
736 2021-11-11 14:26 Anonymous (not verified) 72.13.16.172 All Seasons Trucking Inc Proprietorship S11689 CTY RD G I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-11-18 FARGEN TRUCKING dave@allseasonstrucking.com SPRING GREEN SAUK WI DAVE NEUWOHNER BEN MOYER Signed (1) The employer does not elect the employers’ liability coverage. FARGEN TRUCKING DAVE@ALLSEASONSTRUCKING.COM PRESIDENT SPRING GREEN SAUK WI Dave Neuwohner BEN MOYER Signed
871 2022-01-29 15:43 Anonymous (not verified) 173.31.116.134 West cleaning Proprietorship 8925 Cascade 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. 2022-01-29 Fata Omerovic fataomerovic@msn.com West Des Moines IA Iowa Semir Omerovic Samir Omerovic Signed (1) The employer does not elect the employers’ liability coverage. Fata Omerovic fataomerovic@msn.com Same person West Des Moines IA Iowa Semir Omerovic Samir Omerovic Signed
1836 2023-09-11 09:26 Anonymous (not verified) 94.188.205.174 Felisha Schmitz Proprietorship 505 Q AVENUE MILFORD IA 51351 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-08 FELISHA SCHMITZ PETERNFISH@GMAIL.COM MILFORD DICKINSON IA JENNIFER YOUNGWIRTH TAMI KLEIN Signed (1) The employer does not elect the employers’ liability coverage. FELISHA SCMITZ PETERNFISH@GMAIL.COM SELF MILFORD DICKINSON IA JENNIFER YOUNGWIRTH TAMI KLEIN Signed
687 2021-10-22 11:07 Anonymous (not verified) 65.144.174.26 Fernando Garcia Proprietorship 8952 Long Meadow Dr Johnston, IA 50131 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-22 Fernando Garcia gfernando5030@gmail.com johnston polk Iowa Javier Manriquez Josefina Chavez Signed (1) The employer does not elect the employers’ liability coverage. Fernando Garcia gfernando5030@gmail.com Owner Johnston Polk Iowa Javier Manriquez Josefina Chavez Signed
1552 2023-04-03 13:58 Anonymous (not verified) 94.188.205.168 F&I Drywall Llc Limited Liability Company 509 Arlington Dr. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-03 Fernando Garcia Fgarcia1989.fg@gmail.com Marshalltown Marshall Iowa Gabriela Garcia Araceli Tafolla Signed (1) The employer does not elect the employers’ liability coverage. Fernando Garcia Fgarcia1989.fg@gmail.com Self Marshalltown Marshall Iowa Gabriela Garcia Araceli Tafolla Signed
2160 2024-04-17 18:21 Anonymous (not verified) 94.188.207.226 QC Remodeling LLC Limited Liability Company 421 West Broadway, Ste 302 Council Bluffs, IA 51503 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-17 Fernando Ibarra ibarra_fernando@hotmail.com Rock Island Rock Island Illinois Paula Barria Louis Valencia Signed (1) The employer does not elect the employers’ liability coverage. Fernando Ibarra ibarra_fernando@hotmail.com Owner Rock Island Rock Island Illinois Paula Barria Louis Valencia Signed
232 2020-08-16 11:28 Anonymous (not verified) 173.27.57.39 Landeros & Sons Construction, Inc Limited Liability Partnership 1636 19th Avenue I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-16 Fernando Landeros fland1983@gmail.com Moline Rock Island Illinois Adrian Landeros Emanuel Landeros Signed (1) The employer does not elect the employers’ liability coverage. Emanuel Landeros fland1983@gmail.com Brother Moline Rock Island Illinois Adrian Landeros Emanuel Landeros Signed
667 2021-10-11 19:33 Anonymous (not verified) 104.166.240.24 FS Custom Flooring Limited Liability Company 5729 NW 92nd 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. 2021-10-11 Filip Sakanovic filip@fscustomflooring.com Johnston IA United States Senad Sakanovic Filip Sakanovic Signed (1) The employer does not elect the employers’ liability coverage. FS Tiling and Ceramics filip@fscustomflooring.com N/A Johnston IA United States Senad Sakanovic Filip Sakanovic Signed
1515 2023-03-13 15:04 Anonymous (not verified) 94.188.207.226 Flint Hillman Proprietorship 1019 E 17th St, APT 16, 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. 2023-03-13 Flint Hillman flinthillman@gmail.com Norwalk Warren Iowa Tina Robinson Paige Robinson Signed (1) The employer does not elect the employers’ liability coverage. Flint Hillman flinthillman@gmail.com Self Norwalk Warren Iowa Tina Robinson Paige Robinson Signed
72 2020-02-21 09:43 Anonymous (not verified) 98.18.174.183 Forrest E. Whitford DVM LLC Limited Liability Company P.O. Box 120 - 507 Washington Street, Volga, IA 52077 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-21 Forrest E. Whitford, DVM LLC gfw54@hotmail.com Volga, IA Clayton Iowa Glenna Whitford Pam Vaske Signed (1) The employer does not elect the employers’ liability coverage. Forrest E. Whitford, DVM LLC gfw54@hotmail.com self Volga Clayton Iowa Glenna Whitford Pam Vaske Signed
2045 2024-02-15 10:26 Anonymous (not verified) 94.188.207.227 Francesco Martinez Proprietorship 403th 7th Ave NW Clarion IA 50525 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-15 Francesco Martinez Martinexfrancesco99@gmail.com Clarion Wright Iowa Jason W Helmers Josh W Helmers Signed (1) The employer does not elect the employers’ liability coverage. Francesco Martinez martinezfrancesco99@gmail.com Employer Clarion Wright Iowa Jason W Helmers Josh W Helmers Signed
1960 2023-12-16 11:58 Anonymous (not verified) 94.188.207.227 Landeros Framing Proprietorship 2418 E 37th Ct I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-16 Francisco Javier Landeros Garcia garcialanderosfranciscojavier@gmail.com Des Moines IA IA Mirna Ruby Jose Gaytan Signed (1) The employer does not elect the employers’ liability coverage. Francisco Javier Landeros Garcia garcialanderosfranciscojavier@gmail.com owner Des Moines IA IA Mirna Ruby Jose Gaytan Signed
2039 2024-02-08 09:25 Anonymous (not verified) 94.188.207.229 Home Re Construction, LLC Limited Liability Company 5285 NE Mitchell Drive, Mitchellville, IA 50169 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-08 Francisco Miguel Palomares Velasco homereconstruction@hotmail.com Mitchellville Polk Iowa Fabiola Palomares Recendiz Nathan Miller Signed (1) The employer does not elect the employers’ liability coverage. Francisco Miguel Palomares Velasco homereconstruction@hotmail.com Self Mithcellville Polk Iowa Fabiola Palomares Recendiz Nathan Miller Signed
2187 2024-04-29 08:30 Anonymous (not verified) 94.188.207.226 Fran Stonework LLC Limited Liability Company 1222 E Seneca Ave Apt 7, Des Moines, IA 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-29 Francisco Rodriguez Rios panchito941@icloud.com Des Moines Polk Iowa Fabiola Palomares Nathan Miller Signed (1) The employer does not elect the employers’ liability coverage. Francisco Rodriguez Rios panchito941@icloud.com Self Des Moines Polk Iowa Fabiola Palomares Nathan Miller Signed
603 2021-08-14 09:39 Anonymous (not verified) 173.20.168.51 Leaf Filter Proprietorship 3060 Southeast Grimes Boulevard I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-08-14 Francisco Salgado fsalgado1989@gmail.com Perry IA United States Wendy Asturias Susana Romero Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Leaf Filter macosta@leafhome.com none Grimes Polk Iowa Wendy Asturias Susana Romero Signed
493 2021-04-22 08:54 Anonymous (not verified) 66.188.136.150 Frank Lantz Proprietorship 609 Clinton Street, Charles City, IA 50616 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-21 Frank Lentz kschumacher@tricorinsurance.com Charles City Floyd IA Shuree Behr Mitch Kemp Signed (1) The employer does not elect the employers’ liability coverage. Frank Lantz kschumacher@tricorinsurance.com Same Charles City Floyd IA Shuree Behr Mitch Kemp Signed
879 2022-01-31 14:26 Anonymous (not verified) 173.27.146.201 Premier Window Cleaning LLC Limited Liability Company 420 E GRANGER 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. 2022-01-31 Frank Viola premierofiowa@gmail.com DES MOINES IA United States Ron Reynolds Chris Greco Signed (1) The employer does not elect the employers’ liability coverage. Frank Viola premierofiowa@gmail.com my self DES MOINES IA United States Ron Reynolds Chris Greco Signed
1601 2023-04-25 14:38 Anonymous (not verified) 94.188.207.230 francisco garcia Proprietorship 388 lesley ln 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. 2023-04-25 franscisco garcia frasicohinojosa@gmail.com cedar rapids linn iowa Ryan Klein Karina Jacobson Signed (1) The employer does not elect the employers’ liability coverage. francisco garcia frasicohinojosa@gmail.com N/A cedar rapids linn iowa Ryan Klein Karina Jacobson Signed
1530 2023-03-23 16:14 Anonymous (not verified) 94.188.205.166 Los Cousins gutters Limited Liability Company 901 sw 62nd st des moines ia 50312 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-23 Freddy Morales 1981ayoria@gmail.com Des Moines Ia Polk Iowa Denni bazan Dionicio morales Signed (1) The employer does not elect the employers’ liability coverage. Freddy Morales 1981ayoria@gmail.com 1981ayoria@gmail.com Desmoines Polk Ia Dennis Bazan Dionicio Morales Signed
1058 2022-04-19 13:19 Anonymous (not verified) 50.83.154.192 Property Maintenance Services of Iowa LLC Limited Liability Company PO Box 166 Low Moor IA 52757 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Frederick Stewart curlyfry42000@yahoo.com LOW MOOR IA United States Irene R Stewart Derek S Jensen Signed (1) The employer does not elect the employers’ liability coverage. Frederick Lee Stewart zombiesby2012@gmail.com Owner Clinton IA United States Irene R Stewart Derek S Jensen Signed
65 2020-02-18 15:44 Anonymous (not verified) 70.58.180.91 TD & I CABLE MAINTENANCE INC. Proprietorship P.O. BOX 266 LAKELAND MN. 55043 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-18 FREDERICK W GREEN FREDGREENCONSTRUCTION@YAHOO.COM DES MOINES POLK IOWA KATHYRN EILEEN WILLIAMSON MICHAEL BOYD WILLIAMS Signed (1) The employer does not elect the employers’ liability coverage. LIZZY SHEPARD LIZZYSHEPARD@TDICABLE.COM SUBCONTRACTOR LAKELAND WASHINGTON MINNESOTA KATHRYN EILEEN WILLIAMSON MICHAEL BOYD WILLIAMS Signed
272 2020-10-02 13:10 Anonymous (not verified) 99.203.92.229 Batres Homes Renovation LLC Limited Liability Company 3000 2nd Ave Des Moines Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-02 Gabriel Antonio Batres Huezo gabirlebatres7@gmail.com Des Moines Polk Iowa Blanca Silvia Leiva Luis Mariano Signed (1) The employer does not elect the employers’ liability coverage. Walter Alexander Batres Huezo wbatres12@gmail.com Employer Des Moines Polk Iowa Blanca Silvia Leiva Luis Mariano Signed
447 2021-03-24 14:09 Anonymous (not verified) 208.90.15.53 Gabe Saenz, LLC Limited Liability Company PO Box 53 Humboldt, IA 50548 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-24 Gabriel Saenz gsaenzh@gmail.com Humboldt Humboldt Iowa Lance DeWinter Cathy Schipull Signed (1) The employer does not elect the employers’ liability coverage. Gabriel Saenz gsaenzh@gmail.com Owner Humboldt Humboldt Iowa Lance DeWinter Cathy Schipull Signed
675 2021-10-15 11:22 Anonymous (not verified) 75.162.156.37 MCG FLOORING, LLC Limited Liability Company 2115 CARPENTER AVE DES MOINES IA 50311 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-15 GABRIELA GOMEZ MCGFLOORINGLLC@GMAIL.COM DES MOINES USA IA YOLANDA MENDOZA LILIANA SANCHEZ GUTIERREZ Signed (1) The employer does not elect the employers’ liability coverage. MCG FLOORING, LLC MCGFLOORINGLLC@GMAIL.CON OWNER DES MOINES USA IA YOLANDA MENDOZA LILIANA SANCHEZ GUTIERREZ Signed
1873 2023-10-20 09:25 Anonymous (not verified) 94.188.207.228 GC Hauling LLC Limited Liability Company 310 North 18th Street, Indianola, IA, 50125 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-20 Garrett Joseph Claerhout gjclaerhout@hotmail.com INDIANOLA IA IA Kirsten Claerhout Jay Claerhout Signed (1) The employer does not elect the employers’ liability coverage. Garrett Joseph Claerhout gjclaerhout@hotmail.com Same Person INDIANOLA IA IA Kirsten Claerhout Jay Claerhout Signed
26 2020-01-04 17:23 Anonymous (not verified) 45.53.67.52 Gary De Jager Limited Liability Company 417 florida Ave NW Orange City Iowa 51041 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-04 Gary Dean De Jager mightyspear60@yahoo.com Orange City Souix Iowa Brody Dean De Jager Tyler Ray De Jager Signed (1) The employer does not elect the employers’ liability coverage. Gary Dean De Jager mightyspear60@yahoo.com owner Orange City souix Iowa Brody Dean De Jager Tyler Ray De Jager Signed
867 2022-01-28 12:19 Anonymous (not verified) 207.199.212.86 Gary Elsbernd DBA RGM Dairy Farm Proprietorship 1538 230th St Calmar IA, 52132 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-21 Gary Elsbernd lacy@cioia.com Calmar Winneshiek Iowa Joel Rochford Lacy Carolan Signed (1) The employer does not elect the employers’ liability coverage. Gary Elsbernd lacy@cioia.com Self Calmar Winneshiek Iowa Joel Rochford Lacy Carolan Signed
1735 2023-07-11 08:28 Anonymous (not verified) 94.188.207.229 LBN LLC Limited Liability Company 1930 se 14th Des Moines Iowa 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-11 Gary Fatino fatinomarketinggroup@yahoo.com Des Moines polk Iowa Liana Fatino Gary Fatino Signed (1) The employer does not elect the employers’ liability coverage. Gary Fatino fatinomarketinggroup@yahoo.com owner des moines polk iowa liana fatino gary fatino Signed
1737 2023-07-11 08:32 Anonymous (not verified) 94.188.207.223 Scornos waukee llc Limited Liability Company 286 w hickman rd waukee iowa 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-11 Gary Fatino fatinomarketinggroup@yahoo.com des moines polk iowa Liana Fatino Gary Fatino Signed (1) The employer does not elect the employers’ liability coverage. Gary Fatino fatinomarketinggroup@yahoo.com owner des moines polk iowa Liana Fatino Gary Fatino Signed
2104 2024-03-18 12:36 Anonymous (not verified) 94.188.205.167 Scornoos 1973 INC Proprietorship 8561 hickman rd urbandale iowa 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-18 Gary Fatino lfatino@yahoo.com des moines Polk iowa Liana Fatino LISA VACCO Signed (1) The employer does not elect the employers’ liability coverage. Liana Fatino lfatino@yahoo.com wife des moines polk iowa Liana Fatino Lisa vacco Signed
2106 2024-03-18 12:47 Anonymous (not verified) 94.188.205.167 Scornos Altoona LLC Proprietorship 2437 adventureland dr altoona iowaa 50009 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-18 Gary Fatino lfatino@yahoo.com des moines POLK IOWA Liana Fatino LISA VACCO Signed (1) The employer does not elect the employers’ liability coverage. Liana Fatino lfatino@yahoo.com wife des moines polk iowa Liana Fatino Lisa Vacco Signed
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
287 2020-10-21 18:35 Anonymous (not verified) 173.218.73.44 Bilyeu Underground LLC Limited Liability Company 1136 W. Irene Ct. Nixa, MO 65714 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-21 Gary George Bilyeu garygb1990@gmail.com Sparta Christian Missouri Daniel Bilyeu Chad Anthony Charles Signed (1) The employer does not elect the employers’ liability coverage. Gary George Bilyeu garygb1990@gmail.com Owner Sparta Christian Missouri Chad Anthony Charles Daniel Bilyeu Signed
298 2020-10-30 10:45 Anonymous (not verified) 216.51.132.207 Kregel Farm Partnership LLP Limited Liability Partnership 30392 Garber RD Guttenberg, IA 52052 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-08 Gary Kregel TRAVIS.KREGEL@GMAIL.COM Guttenberg Clayton Iowa Jerry J Rochford Nicole L Parker Signed (1) The employer does not elect the employers’ liability coverage. Gary Kregel TRAVIS.KREGEL@GMAIL.COM same Guttenberg Clayton Iowa Jerry J Rochford Nicole L Parker Signed
983 2022-03-18 11:02 Anonymous (not verified) 66.180.9.84 Gary Runyon Proprietorship 101 Harris St Ste 1 Hastings, IA 51540 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-18 Gary Runyon garyrunyon26@gmail.com Henderson Mills Iowa Gary Runyon Cathy Mardesen Signed (1) The employer does not elect the employers’ liability coverage. Gary Runyon garyrunyon26@gmail.com owner Henderson Mills Iowa Gary Runyon Cathy Mardesen Signed
1253 2022-08-12 14:43 Anonymous (not verified) 173.23.251.188 GLBH, LLC Proprietorship 3396 268th St Linden, IA 50146 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-12 Gavin Lamb gavinglbh@outlook.com Linden Guthrie IA Tara Murphy Nick Stevens Signed (1) The employer does not elect the employers’ liability coverage. Gavin Lamb gavinglbh@outlook.com self Linden Guthrie IA Tara Murphy Nick Stevens Signed
2188 2024-04-29 09:05 Anonymous (not verified) 94.188.207.229 General Lee Franklin Proprietorship 820 Oak Street, 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. 2024-04-25 General Lee Franklin gleef1966@gmail.com Burlington Des Moines Iowa Cheryl Ross Larry Rheinschmidt Signed (1) The employer does not elect the employers’ liability coverage. General Lee Franklin gleef1966@gmail.com owner Burlington Des Moines Iowa Cheryl Ross Larry Rheinschmidt Signed
1258 2022-08-15 13:30 Anonymous (not verified) 173.29.47.222 Premiere Plastering & Drywall, Inc. Proprietorship 2331 W. 63rd 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. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-08-15 George Anthony Loeffelholz tobby.loeffelholz@gmail.com Davenport Iowa United States Jamie Wardlow Kandra Blumenshein Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Premiere Plastering & Drywall, Inc. premiere_pd_llc@yahoo.com Subcontractor Davenport Iowa United States Jamie Wardlow Kandra Blumenshein Signed
2163 2024-04-19 08:53 Anonymous (not verified) 94.188.205.174 George Petree Proprietorship 1219 N 7th 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. 2024-04-19 George Harlan Petree g_petree@hotmail.com Burlington Des Moines Iowa Cheryl Ross Larry Rheinschmidt Signed (1) The employer does not elect the employers’ liability coverage. George Harlan Petree g_petree@hotmail.com owner Burlington Des Moines Iowa Cheryl Ross Larry Rheinschmidt Signed
2063 2024-02-29 10:12 Anonymous (not verified) 94.188.205.177 Geral Lee Pattison Proprietorship 22127 Hwy 52 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-29 Geral Lee Pattison pattisonglee@gmail.com GARNAVILLO IA IA Lee Zapf Andrew Corllet Signed (1) The employer does not elect the employers’ liability coverage. Geral Lee Pattison pattisonglee@gmail.com Self GARNAVILLO IA IA Lee Zapf Andrew Corllet Signed
459 2021-04-05 14:24 Anonymous (not verified) 66.188.136.150 Gerald Bosch Proprietorship 14359 County Rd. G62 Wapello, IA 52653 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-02 Gerald Bosch kschumacher@tricorinsurance.com Wapello Louisa IA Russell Masartis Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Gerald Bosch kschumacher@tricorinsurance.com Same Wapello Louisa IA Russell Masartis Shuree Behr Signed
309 2020-11-09 12:17 Anonymous (not verified) 70.184.213.31 Gerald Gerhardt Proprietorship 104 S 3rd Street, Villisca, IA 50864 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-03 Gerald Gerhardt jerrygerhardt1280@gmail.com Villisca Montgomery IA Tony W. Johnson Gerald Gerhardt Signed (1) The employer does not elect the employers’ liability coverage. Smith Davis Insurance tony@smithdavisins.com Client Papillion Sarpy IA Tony W. Johnson Gerald Gerhardt Signed
680 2021-10-18 13:58 Anonymous (not verified) 166.181.86.88 Gerald Jerome Proprietorship 2668 Wapsi Ridge Dr. Walker, IA 52352 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-18 Gerald Jerome geraldjerome373@ymail.com Walker IA United States Benjamin J Barkalow James M. Barkalow Signed (1) The employer does not elect the employers’ liability coverage. Gerald Jerome geraldjerome373@ymail.com Self employed Walker Linn Iowa Benjamin J Barkalow James M Barkalow Signed
594 2021-08-03 13:12 Anonymous (not verified) 166.181.80.73 Leaffilter Limited Liability Company 866 40th Ave Bettendorf, IA 52722 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-03 Gerald Landstrum Teamtony710@gmail.com 103 e Grinnell street Gibson Iowa Keokuk Iowa Jake Nagel Ty Reindl Signed (1) The employer does not elect the employers’ liability coverage. LeafFilter Gutter Protection jnagel@leafhome.com assembler Bettendorf Scott Iowa Jake nagel Ty reindl Signed
822 2022-01-04 16:59 Anonymous (not verified) 173.22.62.131 Gerardo Calvillo Limited Liability Company 1802 mondamin ave,Des Moines,iowa. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-04 Gerardo Calvillo joedhsanchez@icloud.com Des Moines Polk Iowa Aurora Maciel colín Gerardo Calvillo Signed (1) The employer does not elect the employers’ liability coverage. Gerardo Calvillo joedhsanchez@icloud.com Self Des Moines Polk Iowa Aurora maciel colín Gerardo Calvillo Signed
1474 2023-02-20 19:48 Anonymous (not verified) 94.188.207.230 Individual entity Proprietorship 801 CELTIC DR, Waukee IA 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-20 Gerardo Castro jackiecastro18@gmail.com Waukee IA United States Jackelin Castro Esmeralda Castro Signed (1) The employer does not elect the employers’ liability coverage. Gerardo Castro jackiecastro18@gmail.com self Waukee Dallas Iowa Jackelin Castro Esmeralda Castro Signed
1648 2023-05-16 08:16 Anonymous (not verified) 94.188.205.169 Hernandez Drywall Proprietorship 2001 8th St Coralville, IA 52241 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-16 Gerardo Hernandez gerardohernandez56u@gmail.com Coralville Johnson Iowa Brad Bower Kirk Strucnk Signed (1) The employer does not elect the employers’ liability coverage. Gerardo Hernandez gerardohernandez56u@gmail.com Self Coralville Johnson iowa Brad Bower Kirk Strunk Signed
1689 2023-06-13 19:55 Anonymous (not verified) 94.188.207.227 Gerardo Reyes-Lopez Limited Liability Company 908 West 1st Street, Waterloo, IA ,50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-13 Gerardo Reyes-lopez greyeslopez9@gmail.com Waterloo Black Hawk Iowa Guillermina Lopez Bernardo Reyes Signed (1) The employer does not elect the employers’ liability coverage. Denise Seitsinger denise@harmsinsuranceagency.com Insurance Agent Sumner Bremer Iowa Gerardo Reyes Bernardo Reyes Signed
1690 2023-06-13 20:01 Anonymous (not verified) 94.188.207.227 Gerardo Reyes-Lopez Limited Liability Company 908 West 1st Street, Waterloo, Iowa, 50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-13 Gerardo Reyes-lopez bernardo@reyesconstruct.com Waterloo IA United States Guillermina Lopez Bernardo Reyes Signed (1) The employer does not elect the employers’ liability coverage. Denise Seitsinger denise@harmsinsuranceagency.com Insurance Agent Sumner Bremer Iowa Gerardo Reyes Bernardo Reyes Signed
1021 2022-03-30 11:20 Anonymous (not verified) 173.18.22.217 Arti Concrete Limited Liability Company 6901 SE 14th St Lot #226 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. 2022-03-30 Gerson David Artero arti.concrete31@gmail.com Des Moines Polk IA Lesa Reeves Erick Schuldt Signed (1) The employer does not elect the employers’ liability coverage. Gerson David Artero arti.concrete31@gmail.com Owner Des Moines Polk IA Lesa Reeves Erick Schuldt Signed
703 2021-11-01 11:25 Anonymous (not verified) 65.144.174.26 G & D Tile Proprietorship 2210 E Rose Ave Apt 9 Des Moines, IA 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-01 Gerson Mejia gersonmejia25@icloud.com Des Moines Polk Iowa Katherine Castillo Jose Leonardo Signed (1) The employer does not elect the employers’ liability coverage. Gerson Mejia gersonmejia25@icloud.com Owner Des Moines Polk Iowa Katherine Castillo Jose Leonardo Signed
1095 2022-05-12 13:20 Anonymous (not verified) 173.31.29.53 Leaf cutter protection Limited Liability Company 4146 East 23rd 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. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-05-12 Gideon Lagat gsaina78@gmail.com Des Moines IA United States Priscilla saina Cosmas nyaika Signed (1) The employer does not elect the employers’ liability coverage. Mark rond mbond@leaffilter.com Regional installation Manager Grimes Polk Iowa Priscilla saina Cosmas nyaika Signed
1182 2022-07-06 13:40 Anonymous (not verified) 50.80.25.116 Beast Construction LLC Limited Liability Company 1025 O Ave NW I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-11 Gilberto Vasquez (GV Construction LLC) Normambazquez@gmail.com Iowa City IA United States Pedro Pinto Rafael Garcia Signed (1) The employer does not elect the employers’ liability coverage. Greg Saunders gsaunders@beastconstructioncr.com Owner CEDAR RAPIDS IA United States Laura Saunders Joanie Lacayo Signed
712 2021-11-05 10:38 Anonymous (not verified) 64.5.73.247 Glenn Langel Proprietorship 20581 300th St, Templeton, IA 51463 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-29 Glenn Langel gklangel@netins.net Templeton Carroll Iowa Jonathan Heydon Mitchell Langel Signed (1) The employer does not elect the employers’ liability coverage. Glenn Langel gklangel@netins.net Owner Templeton Carroll Iowa Jonathan Heydon Mitchell Langel Signed
196 2020-06-30 23:17 Anonymous (not verified) 72.46.186.211 Artie's Construction Proprietorship 520 5th Ave Sibley, IA 51249 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-30 Gloria Esther Torres torrglo@hotmail.com Sibley Osceola Iowa Laura Barrie Morgen Gonzalez Signed (1) The employer does not elect the employers’ liability coverage. Gloria Esther Torres torrglo@hotmail.com Self Sibley Osceola Iowa Laura Barrie Morgen Gonzalez Signed
1982 2024-01-11 12:29 Anonymous (not verified) 94.188.205.166 Grace Justine Proprietorship 405 Northview Drive I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-11 Grace Justine Wandera / Independent Contractor justine.wandera@candeoiowa.org Waukee IA IA Grace Justine Wandera / Independent Contractor Grace Justine Wandera / Independent Contractor Signed (1) The employer does not elect the employers’ liability coverage. Grace Justine Wandera / Independent Contractor justine.wandera@candeoiowa.org own Waukee IA IA Grace Justine Wandera / Independent Contractor Grace Justine Wandera / Independent Contractor Signed
2149 2024-04-15 11:20 Anonymous (not verified) 94.188.207.224 Grady Yeggy Proprietorship 211 3rd St. Riverside, IA 52327 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-11 Grady S Yeggy kellylanz1967@gmail.com Riverside IA United States Amanda Yeggy Leah Evans Signed (1) The employer does not elect the employers’ liability coverage. Grady S Yeggy kellylanz1967@gmail.com Self Riverside IA United States Amanda Yeggy Leah Yeggy Signed
857 2022-01-26 16:27 Anonymous (not verified) 207.199.212.86 Grahm's Tree Service Proprietorship 406 2nd Ave Charles City, IA 50616 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-22 Graham Kuethe lacy@cioia.com Charles City Floyd Iowa Lacy Carolan Tony Trower Signed (1) The employer does not elect the employers’ liability coverage. Graham Kuethe lacy@cioia.com Owner Charles City Floyd Iowa Lacy Carolan Tony Trower Signed
1623 2023-05-02 14:09 Anonymous (not verified) 94.188.207.226 Leafhome Solutions LLC Limited Liability Company 1595 Georgetown Road 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. 2023-05-02 Grant Anders Scott G2designLLC@yahoo.com Des Moines Polk Iowa Katherine Scott Brian Yurko Signed (1) The employer does not elect the employers’ liability coverage. Brian Yurko byurko@leafhome.com Recruiter Hudson Summit Ohio Katherine Scott Grant Scott Signed
251 2020-09-08 17:00 Anonymous (not verified) 173.27.45.95 Peerless Construction, LLC Limited Liability Company 4718 E 49th Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-08 Grant Jipp grant.peerless@gmail.com Davenport Scott Iowa Dan Knight Bridget Knight Signed (1) The employer does not elect the employers’ liability coverage. Grant Jipp grant.peerless@gmail.com Owner Davenport Scott Iowa Dan Knight Bridget Knight Signed
866 2022-01-27 19:15 Anonymous (not verified) 199.66.15.25 Greg Cheno Services LLC Limited Liability Company 203 N H 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. 2022-01-27 Gregory Chenoweth gregcheno@gmail.com Indianola IA United States Rebecca Sue Abbott Gregory Blair Abbott Signed (1) The employer does not elect the employers’ liability coverage. Gregory J. Chenoweth gregcheno@gmail.com Same Indianola Warren Iowa Rebecca Sue Abbott Gregory Blair Abbott Signed
62 2020-02-17 06:55 Anonymous (not verified) 173.31.111.29 Pa's Construction LLC Limited Liability Company 2350 Glass Rd NE, Cedar Rapids, IA 52402 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-17 Gregory Daniel Saunders gsaunders.pas@gmail.com CEDAR RAPIDS IOWA United States Laura Sturm Chad Johnson Signed (1) The employer does not elect the employers’ liability coverage. Daniel Saunders dan2112411@yahoo.com Owner Cedar Rapids Linn Iowa Walt Cheney Mike Broghammer Signed
361 2021-01-12 16:04 Anonymous (not verified) 50.82.130.211 Gregory Lievens Partnership 503 N. Main Street, Allison 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. 2021-01-12 Gregory Lievens cmins_re@mchsi.com Allison Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Gregory Lievens cmins_re@mchsi.com Self Allison Butler Iowa Chad Campbell Roxanne Kolder Signed
280 2020-10-20 08:02 Anonymous (not verified) 98.23.12.154 Peters Painting Proprietorship 11286 290th Manning IA 51455 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-20 gregory peters rangreg@windstream.net Manning Carroll IA Amy Hansen Todd Stadtlander Signed (1) The employer does not elect the employers’ liability coverage. Gregory Peters rangreg@windstream.net self Manning Carroll IA Amy Hansen Todd Stadtlander Signed
1752 2023-07-17 13:21 Anonymous (not verified) 94.188.207.225 GPS Construction Limited Liability Company 920 Wolf Creek 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. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2023-07-17 Gregory Schultz gregpschultz@gmail.com POLK CITY IA United States Dillon Temple Derek Temple Signed (1) The employer does not elect the employers’ liability coverage. Gregory Schultz gregpschultz@gmail.com Owner POLK CITY IA United States Dillon Temple Derek Temple Signed
601 2021-08-12 16:37 Anonymous (not verified) 172.58.83.7 C & G Construction LLC Limited Liability Company 659 Sw Springfield Dr I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-12 Griselda Corona candgconst@gmail.com Ankeny Polk IA Clifton Kinney Marisol Chavira Signed (1) The employer does not elect the employers’ liability coverage. Juan Carlos corona candgconst@gmail.com Partner Ankeny Polk IA Clifton Kinney Marisol Chavira Signed
1647 2023-05-15 14:11 Anonymous (not verified) 94.188.207.227 Innovators construction llc Limited Liability Company 3234 180th St. Homestead, IA 52236 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Guadalupe Ramirez info@jmdrywallonline.com Homestead Iowa Iowa Itali Ramírez Manuela Muñoz Signed (1) The employer does not elect the employers’ liability coverage. Juan M Ramírez info@jmdrywallonline.com Owner/spouse Homestead Iowa Iowa Itali Ramírez Manuela Muñoz Signed
1740 2023-07-11 12:22 Anonymous (not verified) 94.188.205.168 Innovators Construction LLC Limited Liability Company 3234 180th St., Homestead, IA 52236 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-11 Guadalupe Ramirez imfo@jmdrywallonline.com Homestead Iowa Iowa Itali Ramírez Juan m Ramírez Signed (1) The employer does not elect the employers’ liability coverage. Juan M Ramírez info@jmdrywallonline.com Business partner Homestead Iowa Iowa Itali Ramírez Juan m Ramírez Signed
774 2021-11-29 12:28 Anonymous (not verified) 174.198.82.208 Demetrio's Construction Proprietorship 2018 Heights Ave Sioux City, IA 51104 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-29 Guillermo Demetrio moralesdalia44@yahoo.com Sioux City Woodbury Iowa Dalia E. Morales Galvez Vanessa Topete Signed (1) The employer does not elect the employers’ liability coverage. Guillermo Demetrio moralesdalia44@yahoo.com Owner Sioux City Woodbury Iowa Dalia Morales Galvez Vanessa Topete Signed
977 2022-03-15 12:04 Anonymous (not verified) 38.108.136.192 Gunner Fogle Proprietorship 307 S. Franklin St. Corydon, IA 50060 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-15 Gunner Lee Fogle gunnerfogle@hotmail.com Corydon Wayne IA Jeremy Fogle Erika Fogle Signed (1) The employer does not elect the employers’ liability coverage. Gunner Fogle gunnerfogle@hotmail.com Myself Corydon Wayne IA Jeremy Fogle Erika Fogle Signed
1569 2023-04-12 16:19 Anonymous (not verified) 94.188.205.166 Leaf home solutions llc Limited Liability Partnership 1595 Georgetown rd I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-11 Gustavo Lopez Glopez2616@gmail.com Des Moines IA IA Ricardo lopez Maria lopez Signed (1) The employer does not elect the employers’ liability coverage. N/a sewell@leafhome.com N/a Na Na Na Na Na Signed
1989 2024-01-16 17:13 Anonymous (not verified) 94.188.205.168 Xcel Electric LLC Limited Liability Company 1142 Columbus Dr 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. 2024-01-16 Haris Mumic h.mumic@hotmail.com Waterloo Black Hawk IA Minea Skrgic-Mumic Elvis Mumic Signed (1) The employer does not elect the employers’ liability coverage. Haris Mumic h.mumic@hotmail.com Owner/Employer waterloo Black Hawk IA Minea Skrgic-Mumic Elvis Mumic Signed
653 2021-09-23 15:03 Anonymous (not verified) 72.46.189.33 Feldkamp Farms Inc Partnership 5382 170th St Sibley IA 51249 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-23 Harold P Feldkamp joan@ellerbroekandassociates.com Sibley IA United States Wade Ellerbroek Jr Joan Wallace Signed (1) The employer does not elect the employers’ liability coverage. James Wade Ellerbroek Jr WADE@ELLERBROEKANDASSOCIATES.COM Agent only Sibley IA United States Wade Ellerbroek Jr Joan Wallace Signed
2037 2024-02-07 22:06 Anonymous (not verified) 94.188.205.174 Harold wotton snow and lawn service Proprietorship 117 east kimball st hancock Iowa 51536 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-04 Harold wotton hwotton79@icloud.com Hancock Iowa United States Iowa Crystal Wogomon Brody Weber Signed (1) The employer does not elect the employers’ liability coverage. Harold wotton hwotton79@icloud.com Owner Hancock United States Iowa Crystal Wogomon Brody Weber Signed
247 2020-08-26 20:00 Anonymous (not verified) 67.132.237.42 OPN Renovations LLC Limited Liability Company 1721 63rd St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-26 Haruko Nakata harunakata@hotmail.com Des Moines Iowa United States Monica Parra Oscar D Perez Signed (1) The employer does not elect the employers’ liability coverage. Haruko Nakata harunakata@hotmail.com Single Member Des Moines Iowa United States Monica Parra Oscar D Perez Signed
242 2020-08-24 09:27 Anonymous (not verified) 159.242.43.24 Bontreger Seamless Gutters Proprietorship 501 S Center St. Zearing Ia 50278 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-24 Harvey Bontreger borntrgerharvey@gmail.com Zearing Story Ia Alex G Meier Daniel Wunschel Signed (1) The employer does not elect the employers’ liability coverage. Harvey Bontreger borntrgerharvey@gmail.com Owner Zearing Story Ia Alex G Meier Daniel Wunschel Signed
243 2020-08-24 11:31 Anonymous (not verified) 159.242.43.24 Borntreger Seamless Gutters Proprietorship 501 S Center St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-24 Harvey Borntrager Borntregerharvey@gmail.com Zearing Story Ia Alex G Meier Daniel Wunschel Signed (1) The employer does not elect the employers’ liability coverage. Harvey Borntreger borntregerharvey@gmail.com Owner Zearing Story Ia Alex Meier Daniel Wunschel Signed
131 2020-04-27 15:01 Anonymous (not verified) 66.188.136.150 Hashem Shawki Proprietorship 8906 Newton Ave. 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. 2020-04-27 Hashem Shawki kschumacher@tricorinsurance.com Bloomington Hennepin MN Russell Masartis Nancy Wortley Signed (1) The employer does not elect the employers’ liability coverage. Hasham Shawki kschumacher@tricorinsurance.com Same person Bloomington Hennepin MN Russell Masartis Nancy Wortley Signed
844 2022-01-20 08:55 Anonymous (not verified) 172.58.87.106 Barkley Coatings Limited Liability Company 305 E 20th 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. 2022-01-20 Heath barkleyheath@yahoo.com Newton United States Iowa Matthew Blunk Hailey Scott Signed (1) The employer does not elect the employers’ liability coverage. Heath Barkley barkleyheath@yahoo.com Owner Newton IA United States Matthew Blunk Hailey Scott Signed
90 2020-03-13 15:44 Anonymous (not verified) 173.24.190.134 Heath Householder Limited Liability Company 2 N Huron Street, Emmetsburg IA 50536 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-07 Heath Householder heath679@live.com Emmetsburg Palo Alto Iowa Scott Wirtz Candie Clark Signed (1) The employer does not elect the employers’ liability coverage. Heath Householder heath679@live.com Member of LLC Emmetsburg Palo Alto Iowa Scott Wirtz Candie Clark Signed
91 2020-03-13 15:51 Anonymous (not verified) 173.24.190.134 Small Town RV, LLC Limited Liability Company 112 Miller Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-09 Heath Sabin sales@smalltownrv.com Mallard Palo Alto Iowa Dave Walters Candie Clark Signed (1) The employer does not elect the employers’ liability coverage. Heath Sabin sales@smalltownrv.com Member of LLC Mallard Palo Alto Iowa Dave Walters Candie Clark Signed
939 2022-02-28 13:46 Anonymous (not verified) 173.23.228.17 H & T Ziesman, LLC Limited Liability Company 575 Nuthatch Iowa Falls IA 50126 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-28 Heath Ziesman heathziesman87@gmail.com Iowa Falls Franklin Iowa Jeanne Rieks Kelly Reed Signed (1) The employer does not elect the employers’ liability coverage. Heath ZIesman heathziesman87@gmail.com Owner Iowa Falls Franklin Iowa Jeanne Rieks Kelly Reed Signed
354 2021-01-11 15:04 Anonymous (not verified) 71.199.85.251 Heather Hampton Cooper Consulting, llc Limited Liability Company 412 Mango Cir, Saint Augustine, Florida 32095 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-11 Heather H Cooper hcooper1@comcast.net Saint Augustine Saint Johns FL Terry l. Cooper Lauren Rivera Signed (1) The employer does not elect the employers’ liability coverage. Heather H Cooper hcooper1@comcast.net Owner Saint Augustine Saint Johns FL Terry Cooper Lauren Rivera Signed
43 2020-01-27 09:23 Anonymous (not verified) 71.199.85.251 ATW Training Limited Liability Company 4414 114th Street, Urbandale Iowa 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-25 Heather Hampton Cooper hcooper1@comcast.net Saint Augustine Saint Johns Florida Terry Lee Cooper Stacy Thatcher Signed (1) The employer does not elect the employers’ liability coverage. Lynn Roberts Lynne@atwtraining.com HR Des Moines Polk Iowa Cathy Belmont Mark Purcell Signed
385 2021-02-07 12:43 Anonymous (not verified) 173.17.12.148 H@E roofing LLC Limited Liability Company 1912 Burson street Des Moines is 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-04 Heather Hickman hratherhickman@gmail.com Des moines Polk Iowa Jerry freeborn Ivan torres Signed (1) The employer does not elect the employers’ liability coverage. Heather Hickman hratherhickman@gmail.com Self Des moines Polk Iowa Jerry freeborn Ivan torres Signed
2084 2024-03-08 15:18 Anonymous (not verified) 94.188.207.230 Heidi Vincent Proprietorship 2213 SW White Birch Dr, 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. 2023-09-18 Heidi Vincent jared.vincent@insurancestationinc.com Ankeny Polk Iowa Jared Vincent Colton Horak Signed (1) The employer does not elect the employers’ liability coverage. Mark Schreck mark.schreck@insurancestationinc.com Agent Altoona IA IA Jared Vincent Colton Horack Signed
314 2020-11-13 10:18 Anonymous (not verified) 66.172.192.197 Helaine W. Sherman Trust Proprietorship P.O. Box 717, Sioux City, Iowa 51102 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-13 Helaine W. Sherman Trust, A.F. Baron, Trustee afbaron@baronsar.com Sioux City Woodbury Iowa Joni L. Stieneke Gregory N. Lohr Signed (1) The employer does not elect the employers’ liability coverage. Helaine W. Sherman Trust, A.F. Baron, Trustee afbaron@baronsar.com Trustee of Trust Sioux City Woodbury Iowa Joni L. Stieneke Gregory N. Lohr Signed
924 2022-02-17 13:02 Anonymous (not verified) 208.81.192.69 Wapsie Valley Construction, LLC Limited Liability Company 1154 Dennison Ave., Fairbank, IA 50629 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-17 Henry O. Miller accounting@robertseddy.com Fairbank Buchanan Iowa Brian C. Eddy Samantha J. Stelter Signed (1) The employer does not elect the employers’ liability coverage. Merle Miller accounting@robertseddy.com Same person Fairbank Buchanan Iowa Brian C. Eddy Samantha J. Stelter Signed
249 2020-08-28 13:06 Anonymous (not verified) 97.125.184.147 Supernova Construction LLC Proprietorship 4665 171st St, Urbandale, IA 50323 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-28 Heraclio A Ayala heraclio.ayala@yahoo.com Urbandale Dallas IA Ricardo Alverio Valentin Garcia Signed (1) The employer does not elect the employers’ liability coverage. Heraclio Ayala heraclio.ayala@yahoo.com Sole Member Urbandale Dallas IA Ricardo Alverio Valentin Garcia Signed
504 2021-05-06 15:43 Anonymous (not verified) 75.162.84.34 Erreguin Labra Roofing LLC Limited Liability Company 642 S Washington Ave Mason City IA 50401 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-06 Hilario Labra Trejo erreguin06@gmail.com mason city cerro gordo Iowa Liliana Sanchez Yolanda Mendoza Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Fernando Erreguin Erreguin06@gmail.com member Mason city cerro gordo iowa Liliana sanchez yolanda mendoza Signed
61 2020-02-13 08:44 Anonymous (not verified) 71.28.216.94 Cyclone Captioning, Inc Proprietorship 8866 W 122nd Street N, Mingo, IA 50168 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-13 Holli L. Schneider Hlschneid87@gmail.com Mingo Jasper IA Dan Herrin Minda Dearden Signed (1) The employer does not elect the employers’ liability coverage. Holli Schneider hlschneid87@gmail.com President of Proprietorship Mingo Jasper IA Dan Herrin Minda Dearden Signed
889 2022-02-03 14:52 Anonymous (not verified) 207.177.96.173 Stecker Rentals Inc. Limited Liability Company 1439 Kate Shelley Dr. Boone 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. 2022-02-03 Holly Stecker hollystecker6@gmail.com Boone Boone IA Shana Mallas Laura Hutchcroft Signed (1) The employer does not elect the employers’ liability coverage. Holly Stecker hollystecker6@gmail.com Owner Boone Boone IA Shana Mallas Laura Hutchcroft Signed
1719 2023-07-01 21:34 Anonymous (not verified) 94.188.207.223 Granite & More Limited Liability Company 4730 Tremont ave Davenport Iowa 52807 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-01 Hong Le granite732@yahoo.com Davenport Scott Iowa Jin Chen Betty Song Signed (1) The employer does not elect the employers’ liability coverage. Jin Chen clteam563@gmail.com Manager Bettendorf Scott Iowa Jin Chen Betty Song Signed
1526 2023-03-21 12:24 Anonymous (not verified) 94.188.207.223 Quad Cities Transport Inc Proprietorship 1106 46th ave Rock Island IL 61201 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-21 Howard Davis qctranaportinc@gmail.com East Moline Rock Island Illinois Ricky Oconner Patrick Watkins Signed (1) The employer does not elect the employers’ liability coverage. Howard Davis hdenterprisesinc14@gmail.com Owner East Moline Rock Island Illinois Patrick Watkins Ricky Oconner Signed
1527 2023-03-22 08:35 Anonymous (not verified) 94.188.205.167 Quad Cities Transport Inc Proprietorship 1106 46th ave Rock Island IL 61201 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-21 Howard Rick Clark Davis hdenterprisesinc14@gmail.com East Moline Rock Island IL Patrick Watkins Ricky Oconner Signed (1) The employer does not elect the employers’ liability coverage. Howard Davis qctransportinc@gmail.com Owner East Moline Rock Island Illinois Ricky Oconner Patrick Watkins Signed
805 2021-12-20 08:40 Anonymous (not verified) 65.144.174.26 TILE DECOR INC Proprietorship 1702 WEST 3RD 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. 2021-12-17 HUGO COJON CAMEYHUGO@GMAIL.COM PERRY DALLAS IOWA GABRIELA PEREZ NARCISO HIDALGO Signed (1) The employer does not elect the employers’ liability coverage. HUGO COJON CAMEYHUGO@GMAIL.COM OWNER PERRY DALLAS IOWA GABRIELA PEREZ NARCISO HIDALGO Signed
1412 2023-01-06 12:38 Anonymous (not verified) 72.255.93.91 Espindola Painting Services Proprietorship 4701 Woodland Ave Unit 3, West Des Moines, IA 50266 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-07 Hugo Espindola bmoellers@thebookeepersinc.net Des Moines Polk IA Jenny Espindola Gary Cort Signed (1) The employer does not elect the employers’ liability coverage. Brett Moellers bmoellers@thebookkeepersinc.net Accountant Des Moines Polk IA Jenny Espindola Gary Cort Signed
681 2021-10-19 15:44 Anonymous (not verified) 65.144.174.26 Humberto Albino Proprietorship 3914 Aurora Ave Des Moines, IA 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-19 Humberto Albino albinohumberto73@gmail.com Des Moines Polk Iowa Miguel Albino Jesus Albino Signed (1) The employer does not elect the employers’ liability coverage. Humberto Albino albinohumberto73@gmail.com Owner Des Moines Polk Iowa Miguel Albino Jesus Albino Signed
1563 2023-04-11 08:49 Anonymous (not verified) 94.188.205.168 Ibrahim Sehic Proprietorship 4052 Lafayette Rd, Evansdale, IA 50707 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-11 Ibrahim Sehic bacosidig@gmail.com Evansdale, IA Black Hawk County Iowa Jordan Nisiewicz Jordan Loyd Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay Missouri Jordan Loyd Warren Crow Signed
353 2021-01-11 14:38 Anonymous (not verified) 66.188.136.150 Igor Curguz Proprietorship 927 1/2 W Grand Ave. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-11 Igor Curguz kschumacher@tricorinsurance.com Beloit Rock WI Russell Masartis Nancy Wortley Signed (1) The employer does not elect the employers’ liability coverage. Igor Curguz kschumacher@tricorinsurance.com Same Beloit Rock WI Russell Masartis Nancy Wortley Signed
1444 2023-02-07 14:57 Anonymous (not verified) 173.21.126.4 Rhino Roofing Limited Liability Company 2534 Garfield AVE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-07 Irwins Martinez rhinoroofingsiding21@gmail.com Des Moines Polk Iowa Sara Titus Justin Williams Signed (1) The employer does not elect the employers’ liability coverage. Irwin Martinez rhinoroofing21@gmail.com Self Des Moines Polk Iowa Sara Titus Justin Williams Signed
221 2020-08-03 12:03 Anonymous (not verified) 167.142.196.238 Israel Moreno Proprietorship Po Box 186 Williams, IA 50271 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-12 Israel Moreno mikjuniormoreno@hotmail.com Williams Hamilton Iowa Justin J Malloy Myndi Grimsley Signed (1) The employer does not elect the employers’ liability coverage. Israel Moreno mikjuniormoreno@hotmail.com owner Williams Hamilton Iowa Justin J Malloy Myndi Grimsley Signed
814 2021-12-27 13:07 Anonymous (not verified) 216.51.155.17 I & B Ag Supply, LLC Limited Liability Company 3807 20th Ave Fenton, IA 50539 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-27 Israel Winter israel.winter@hotmail.com Fenton Kossuth Iowa Jonathan Gesink Benjamin Wiersma Signed (1) The employer does not elect the employers’ liability coverage. Israel Winter israel.winter@hotmail.com Member Fenton Kossuth Iowa Jonathan Gesink Benjamin Wiersma Signed
347 2020-12-31 13:44 Anonymous (not verified) 66.129.217.166 Issis Melissa Nunez Proprietorship 2128 S Riverside Dr. Trl 57, Iowa City, IA 52246 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-12-01 Issis Melissa Nunez tonypauljohnson@yahoo.com Iowa City IA United States Anthony Johnson Olvin Lanza Signed (1) The employer does not elect the employers’ liability coverage. Issis Melissa Nunez tonypauljohnson@yahoo.com Owner Iowa City IA United States Anthony Johnson Olvin Lanza Signed
684 2021-10-20 13:25 Anonymous (not verified) 65.144.174.26 A and H Home Improvement Limited Liability Company 600 NE 64th 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. 2021-10-20 Ivan A. Abel aandhhomeimprovement@gmail.com Des Moines Polk Iowa Ken Krogman Bruce Baumgarn Signed (1) The employer does not elect the employers’ liability coverage. Ivan A. Abel aandhhomeimprovement@gmail.com Self Des Moines Polk Iowa Ken Krogman Bruce Baumgarn Signed
755 2021-11-19 13:25 Anonymous (not verified) 65.144.174.26 Central Iowa Insulation and Floors Inc Proprietorship 14858 118 Ave, Indianola, IA 50125 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-19 Ivan Pilat centraliowaif@gmail.com Indianola Warren Iowa Mark Kapustin Vladimir Orbinan Signed (1) The employer does not elect the employers’ liability coverage. Ivan Pilat centraliowaif@gmail.com Self Indianola Warren Iowa Mark Kapustin Vladimir Orbinan Signed
2139 2024-04-08 10:35 Anonymous (not verified) 94.188.205.168 Professional Hardwood Floors LLC Limited Liability Company 14858 118th Ave, Indianola, IA 50125 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-08 Ivan Pilat professionalfloors@ymail.com Indianola Warren iowa Mark Kapysten Vladmir Orbedan Signed (1) The employer does not elect the employers’ liability coverage. Ivan Pilat professionalfloors@ymail.com Self Indianola Warren Iowa Mark Kapysten Vladmir Orbedan Signed
1862 2023-10-05 14:30 Anonymous (not verified) 94.188.207.225 J trinidad Garcia Ferrer Proprietorship 3722 SE 14th St Apt 9 Des Moines, Iowa 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-01 J Trinidad Garcia Ferrer deb@piciowa.com Des Moines Polk Iowa Deb Stratton Martin Pinon Signed (1) The employer does not elect the employers’ liability coverage. J trinidad Garcia Ferrer deb@piciowa.com self Des Moines Polk IOwa Deb Stratton Martin Pinon Signed
38 2020-01-18 12:15 Anonymous (not verified) 206.109.174.199 BJS Frenchies, LLC Limited Liability Company 20081 Highway J 46 Centerville Iowa 52544 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-06 J. Jamie Tracy jamiespuppies@yahoo.com Centerville Appanoose Iowa Misty O'Hair Casey Leach Signed (1) The employer does not elect the employers’ liability coverage. Bruce E Tracy jamiespuppies@yahoo.com Husband and Co Owner Centerville Appanoose Iowa Misty O'Hair Casey Leach Signed
1424 2023-01-17 17:34 Anonymous (not verified) 173.191.246.189 Jabe Ramsey Proprietorship 216 South Park Street Osceola, IA 50213 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-17 Jabe Hatfield Ramsey jaberamsey@icloud.com Osceola IA United States Sofia Contreras Katie Anne Carson Signed (1) The employer does not elect the employers’ liability coverage. Jabe Ramsey jaberamsey@icloud.com ME Osceola Clarke IOWA Sofia Contreras Katie Anne Carson Signed
1890 2023-11-01 19:22 Anonymous (not verified) 94.188.207.228 JACK SCHADE Proprietorship 911 Broad St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-01 jack allan schade jackschade@yahoo.com Plymouth IA IA jack allan schade jack allan schade Signed (1) The employer does not elect the employers’ liability coverage. jack allan schade jackschade@yahoo.com self Plymouth IA IA jack allan schade jack allan schade Signed
305 2020-11-02 08:40 Anonymous (not verified) 204.124.192.31 JPS Framing Proprietorship 102 WALL AVE - DES MOINES IA 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-02 JACKELYN SANCHEZ JPSFRAMING629@GMAIL.COM DES MOINES POLK IOWA ROGELIO SANCHEZ DOMINIQUE SANCHEZ Signed (1) The employer does not elect the employers’ liability coverage. JUAN SERRANO JPSFRAMING629@GMAIL.COM EMPLOYER DES MOINES POLK IOWA ROGELIO SANCHEZ DOMINIQUE SANCHEZ Signed
1531 2023-03-24 08:40 Anonymous (not verified) 94.188.207.228 Schneiter Insurance and Financial Solutions Limited Liability Company 900 E 3RD 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. 2021-05-01 Jackie Schneiter grlschneiter@gmail.com MONTICELLO IA United States Ronald Schneiter Reagan Schneiter Signed (1) The employer does not elect the employers’ liability coverage. Jacqueline Schneiter jackie@we78ins.com owner ANAMOSA JONES IOWA RONALD SCHNEITER REAGAN SCHNEITER Signed
500 2021-04-29 13:09 Anonymous (not verified) 204.155.61.217 JWJ Home Remodeling LLC Limited Liability Company 16915 Weaver Lake Dr, Maple Grove MN 55311 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-29 Jackson Janzen jacksonjanzen@hailmayday.com Maple Grove hennepin MN Ashley Kraft DocuSign Signed (1) The employer does not elect the employers’ liability coverage. Jackson Janzen jacksonjanzen@hailmayday.com Owner Maple Grove Hennepin MN Ashley Kraft DocuSign Signed
1825 2023-08-30 11:16 Anonymous (not verified) 94.188.207.225 Quad City Glass Proprietorship 1330 N Harrison St. Davenport, 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. 2023-08-30 Jacob Brown quadcityglass@gmail.com Davenport Scott IOWA na na Signed (1) The employer does not elect the employers’ liability coverage. Quad City Glass Quadcityglass@gmail.com employee Davenport Scott IOWA na na Signed
1033 2022-04-05 09:36 Anonymous (not verified) 75.89.4.2 KG Land Works Limited Liability Company PO Box 931 Barnsdall, Oklahoma 74002 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-05 Jacob Curtis Kelley jacobkelley730@gmail.com Barnsdall Osage Oklahoma Josiah Daniel Gott Ainsley Noelle Cunningham Signed (1) The employer does not elect the employers’ liability coverage. Dalton Gardner kglandworks@gmail.com Owner Barnsdall Osage Oklahoma Josiah Daniel Gott Wyatt Ray Slone Signed
692 2021-10-26 14:58 Anonymous (not verified) 65.144.174.26 Jake Kenney Proprietorship 3201 Hillsdale Dr. , Urbandale, IA 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-26 Jacob Daniel Kenney Jakedkenney@hotmail.com Urbandale Polk Iowa Abbey Kenney Jory Ringler Signed (1) The employer does not elect the employers’ liability coverage. Jacob Daniel Kenney jakedkenney@hotmail.com Owner Urbandale polk ia abbey kenney jory ringler Signed
1617 2023-04-28 08:26 Anonymous (not verified) 94.188.207.230 JD Transport Limited Liability Company 24940 247th ave Princeton Iowa 52768 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-28 Jacob Dies jacobdiestransport@gmail.com Princeton Scott Iowa Eric Dies Karri Dies Signed (1) The employer does not elect the employers’ liability coverage. Jacob Dies Jacobdiestransport@gmail.com Self Princeton Scott Iowa Eric Dies Karri Dies Signed
1260 2022-08-16 11:30 Anonymous (not verified) 173.29.47.222 Premiere Plastering & Drywall, Inc. Proprietorship 2331 W. 63rd 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. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-08-16 Jacob Dreifurst j_dreifurst@yahoo.com Colona Henry Illinois Jamie Wardlow Kandra Blumenshein Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Premiere Plastering & Drywall, Inc. premiere_pd_llc@yahoo.com Subcontractor Davenport Iowa United States Jamie Wardlow Kandra Blumenshein Signed
1261 2022-08-16 11:30 Anonymous (not verified) 173.29.47.222 Premiere Plastering & Drywall, Inc. Proprietorship 2331 W. 63rd 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. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-08-16 Jacob Dreifurst j_dreifurst@yahoo.com Colona Henry Illinois Jamie Wardlow Kandra Blumenshein Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Premiere Plastering & Drywall, Inc. premiere_pd_llc@yahoo.com Subcontractor Davenport Iowa United States Jamie Wardlow Kandra Blumenshein Signed
2073 2024-03-04 15:51 Anonymous (not verified) 94.188.207.227 JACOB HANSON Proprietorship 415 N 18TH ST ESTHERVILLE, IA 51334 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-04 JACOB HANSON HANSONONEBOY@GMAIL.COM ESTHERVILLE EMMET IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. JACOB HANSON HANSONONEBOY@GMAIL.COM SELF ESTHERVILLE EMMET IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1375 2022-11-18 10:21 Anonymous (not verified) 166.181.87.119 Heff Built Construction LLC Limited Liability Company 1403 Kodiak Dr NW Cedar Rapids, IA 52405 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-18 Jacob Heffernen jheffernen@gmail.com Cedar Rapids Linn IA Kyle Reid Amanda Frese Signed (1) The employer does not elect the employers’ liability coverage. Jacob Heffernen jheffernen@gmail.com N/A Cedar Rapids Linn IA Kyle Reid Amanda Frese Signed
1390 2022-12-12 10:27 Anonymous (not verified) 97.125.170.79 Norwalk Cleaning Servicesw Limited Liability Company 520 W High 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. 2022-12-12 Jacob Hibbert Maryhib@icloud.com Norwalk IA United States Kyle Grandstaff Nicole Nichols Signed (1) The employer does not elect the employers’ liability coverage. Jacob Hibbert maryhib@icloud.com Self Norwalk Warren United States Kyle Grandstaff Nicole Nichols Signed
760 2021-11-21 16:31 Anonymous (not verified) 107.77.206.216 Jacob Odean Limited Liability Company 6634 Lorton CT. Davenport IA 52807 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Jacob James Odean jodean5725@gmail.com DAVENPORT IA United States James Odean Vickie Odean Signed (1) The employer does not elect the employers’ liability coverage. Jacob James Odean jodean5725@gmail.com Same DAVENPORT SCOTT United States James Odean Vickie Odean Signed
2026 2024-02-07 08:32 Anonymous (not verified) 94.188.205.169 Strong Fencing & Decking LLC Limited Liability Company 343 59th Street Des Moines Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-07 Jacob James Strong strongfencingdecking@gmail.com Des Moines Polk Iowa Paige Crowley Jacob Waugh Signed (1) The employer does not elect the employers’ liability coverage. Jacob Strong strongfencingdecking@gmail.com Owner Des Moines Polk Iowa Paige Crowley Jacob Waugh Signed
1236 2022-08-01 20:06 Anonymous (not verified) 24.149.20.39 Jake's Insulation Proprietorship 2020 Valley High Dr. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-01 Jacob Ryan Smalley jakersmalley@gmail.com Cedar Falls USA Iowa Emily Smalley Ben Smalley Signed (1) The employer does not elect the employers’ liability coverage. Jacob Ryan Smalley jakersmalley@gmail.com Owner Cedar Falls USA Iowa Emily Smalley Ben Smalley Signed
1345 2022-10-25 15:25 Anonymous (not verified) 166.181.82.169 Estling Junk and Garbage Removal Limited Liability Company 660 West Main Street Apt.5 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-10-25 Jacob Steven Estling JacobEstling1@gmail.com Maynard Fayette Iowa Jacob Estling Jacob Estling Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jacob Steven Estling jacobestling1@gmail.com Owner Maynard Fayette Iowa Jacob Estling Jacob Estling Signed
742 2021-11-11 15:14 Anonymous (not verified) 72.13.16.172 JACOB WESLEY JOHNSON Proprietorship 1306 BAXTER 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. 2019-11-18 JACOB WESLEY JOHNSON dave@allseasonstrucking.com FAIRBANK BUCHANAN IA Dave Neuwohner BEN MOYER Signed (1) The employer does not elect the employers’ liability coverage. JACOB WESLEY JOHNSON dave@allseasonstrucking.com PRESIDENT FAIRBANK BUCHANAN IA Dave Neuwohner BEN MOYER Signed
1613 2023-04-27 13:57 Anonymous (not verified) 94.188.207.227 Jacob's Ladder Construction Proprietorship 406 10th st Dallas Center Ia 50063 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-27 Jacob Willis jwillis924@gmail.com Dallas Center IA United States Anibal Bonilla Ed Willis Signed (1) The employer does not elect the employers’ liability coverage. Jacob A Willis jwillis924@gmail.com Owner Dallas Center IA United States Anibal Bonilla Ed Willis Signed
1197 2022-07-11 08:35 Anonymous (not verified) 107.127.35.22 Leaf Filter Limited Liability Partnership 3060 SE Grimes Blvd I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-11 Jacqueline Martínez charamusca05erick@icloud.com West Des Moines United Stated Iowa Melvin Gomez Martín Martínez Signed (1) The employer does not elect the employers’ liability coverage. Leaf Filter support@leafhome.com Sub contractor Grimes United States Iowa Melvin Gomez Martín Martínez Signed
887 2022-02-03 14:05 Anonymous (not verified) 173.27.49.231 Jade Mallicoat coaching Limited Liability Company 1318 se linn 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. 2022-02-03 Jade Mallicoat jade.mallicoat@gmail.com Boone Boone Iowa Cord Anderson Mike Anderson Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jade mallicoat jade.mallicoat@gmail.com Myself Boone Boone Iowa Cord Anderson Mike Anderson Signed
1408 2023-01-04 16:12 Anonymous (not verified) 50.82.188.217 Guerrero Masonry Proprietorship 5003 Keystone Rdg SE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-01 Jaime Guerrero jaime.guerrero@mchsi.com Cedar Rapids IA United States Susan Bender Larry Bender Signed (1) The employer does not elect the employers’ liability coverage. Jaime Guerrero jaime.guerrero@mchsi.com self CEDAR RAPIDS Linn Iowa Susan Bender Larry Bender Signed
756 2021-11-19 14:05 Anonymous (not verified) 65.144.174.26 Jaime Hernandez Lopez Proprietorship 223 N 9th Ave W, Newton, Iowa 50208 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-19 Jaime Hernandez Lopez jaimehernandezlopez81@yahoo.com Newton Jasper Iowa Megan Ackerly Antonio Lopez Signed (1) The employer does not elect the employers’ liability coverage. Jaime Hernandez Lopez jaimehernandezlopez81@yahoo.com Self Newton Jasper Iowa Megan Ackerly Antonio Lopez Signed
2156 2024-04-16 17:00 Anonymous (not verified) 94.188.205.166 BONILLA STONE LLC Limited Liability Company 3201 COLUMBIA ST DES MOINES, IA 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-16 JAIRO JAVIER BONILLA SERRANO jairobonilla509@gmail.com DES MOINES POLK IOWA ROCIO REYES JOSE HERNANDEZ Signed (1) The employer does not elect the employers’ liability coverage. JAIRO JAVIER BONILLA SERRANO jairobonilla509@gmail.com SAME DES MOINES POLK IOWA ROCIO REYES JOSE HERNANDEZ Signed
250 2020-09-01 12:08 Anonymous (not verified) 207.191.193.167 Jairo Varela Roofing Proprietorship 1681 Tofting Ave, Iowa City, IA 52240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-01 Jairo Servellon Varela olvinlanza06@gmail.com Iowa City Johnson IA Jessica Lopez Anthony Johnson Signed (1) The employer does not elect the employers’ liability coverage. Jairo Varela olvinlanza06@gmail.com Same Iowa City Johnson IA Jessica Lopez Anthony Johnson Signed
1966 2023-12-27 13:17 Anonymous (not verified) 94.188.205.177 Jake Borntreger Proprietorship 50 Stone St Clermont, 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. 2022-02-25 Jake Borntreger darrele@ciains.biz Clermont Fayette Iowa Chris Fye Darrel Elsbernd Signed (1) The employer does not elect the employers’ liability coverage. Jake Borntreger darrele@ciains.biz self Clermont Fayette Iowa Chris Fye Darrel Elsbernd Signed
544 2021-06-21 16:10 Anonymous (not verified) 97.125.169.60 Tenant Improvement Services, LLC Limited Liability Company 3011 Justin Drive, Urbandale, IA 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-21 Jake Etter jake@tenantimprovemetnsiowa.com Polk City Polk Iowa Ashley Overton Aylah Etter Signed (1) The employer does not elect the employers’ liability coverage. Jake Etter jake@tenantimprovementsiowa.com Member Polk City Polk Iowa Ashley Overton Aylah Etter Signed
1378 2022-11-21 15:12 Anonymous (not verified) 136.34.59.85 Jake Jones Proprietorship 203 9th Ave. Colona, Il 61241 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-21 Jake Jones jmjones807@gmail.com Colona Henry Illinois Jordan Nisiewicz Jordan Loyd Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Regional Recruiter Kansas City Clay Missouri Jordan Loyd Daniel Neal Signed
1210 2022-07-18 08:15 Anonymous (not verified) 173.22.187.234 Cardinal Rule Handyman Services, LLC Limited Liability Company 1304 E 10th St S, Newton, IA 50208 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-18 James Andrew Dunlap cardinarulehandyman@gmail.com Newton Jasper Iowa Jacinda Marie Dunlap James Thornton Dunlap Signed (1) The employer does not elect the employers’ liability coverage. James Andrew Dunlap cardinalrulehandyman@gmail.com I am the authorized agent Newton Jasper Iowa Jacinda Marie Dunlap James Thornton Dunlap Signed
2067 2024-02-29 16:58 Anonymous (not verified) 94.188.205.166 James Baker Limited Liability Company 1510 E 1st Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-01 James Baker jaykeribaker@yahoo.com Indianola Warren IA Keri Baker Brenan Baker Signed (1) The employer does not elect the employers’ liability coverage. James Baker jaykeribaker@yahoo.com Self Indianola Warren IA Keri Baker Brenan Baker Signed
269 2020-09-23 09:18 Anonymous (not verified) 76.76.239.60 belilove company of Iowa Inc Limited Liability Company 601 south 23rd street Fairfield Iowa 52556 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-20 James Belilove jimb@cec-waterjet.com Fairfield Jefferson Iowa James thompson ellen bowen Signed (1) The employer does not elect the employers’ liability coverage. James Belilove jimb@cec-waterjet.com Owner and president Fairfield Jefferson Iowa James Thompson Ellen Bowen Signed
2121 2024-03-28 00:05 Anonymous (not verified) 94.188.205.176 James bunting Limited Liability Company 6213 ridgewood meadows LN 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. 2024-03-28 James bunting jbflooringtile@gmail.com Cedar Rapids Linn Iowa Codee Marie Matt reynolds Signed (1) The employer does not elect the employers’ liability coverage. James bunting jbflooringtile@gmail.com Myself Cedar Rapids Linn Iowa Codee Marie Matt reynolds Signed
1163 2022-06-23 09:17 Anonymous (not verified) 74.84.106.106 James Chitty Proprietorship 307 2nd St Colo, Ia 50056 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-23 James Chitty techsupport@smartind.com Colo Story IA Tina Owens Kim Owens Signed (1) The employer does not elect the employers’ liability coverage. James Chitty techsupport@smartind.com self Colo Story IA Tina Owens Kim Owens Signed
1494 2023-03-06 08:23 Anonymous (not verified) 94.188.207.223 James Douglas Clemons Proprietorship 3807 SW 3rd 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. 2023-03-06 james clemons james.clemons@grandview.edu des moines Iowa United States james clemons james clemons Signed (1) The employer does not elect the employers’ liability coverage. james clemons james.clemons@grandview.edu myself des moines Iowa United States james clemons james clemons Signed
761 2021-11-22 07:22 Anonymous (not verified) 73.211.163.27 James crockett Limited Liability Company 417 easr st south Kewanee il 61443 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-22 James crockett tattoojec@gmail.com Kewanee il Henery Il Tom mcintire Colton english Signed (1) The employer does not elect the employers’ liability coverage. Hog city construction tattoojec@gmail.com Self Kewanee Henery Il Tom mcintire Colon english Signed
608 2021-08-17 21:35 Anonymous (not verified) 50.82.65.174 33z Racing, LLC Limited Liability Company 307 N Park Ave, New Sharon, IA. 50207 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-17 James D VanderBeek jvanderbeek@plbci.com New Sharon Mahaska IA Barbara M VanderBeek Zackery James VanderBeek Signed (1) The employer does not elect the employers’ liability coverage. Barbara M VanderBeek bvanderbeek33z@gmail.com Spouse New Sharon Mahaska IA James D VanderBeek Zackery J VanderBeek Signed
612 2021-08-19 21:50 Anonymous (not verified) 50.82.65.174 33z Racing,, LLC Limited Liability Company 307 N Park Ave, New Sharon, Iowa 50207 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-20 James Dean VanderBeek jvanderbeek@plbco.com New Sharon Mahaska Iowa Margaret Ratcliff Billy Blake Signed (1) The employer does not elect the employers’ liability coverage. Barbara M VanderBeek bvanderbeek33z@gmail.com Spouse New Sharon Mahaska Iowa Margaret Ratcliff Billy Blake Signed
1250 2022-08-10 09:10 Anonymous (not verified) 75.162.190.54 Merit Paint Company Proprietorship 1629 24th St, Des Moines, IA 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-10 James Edward Simpson jaybirdsimpson40@aol.com Des Moines Polk Iowa Regan Simpson Hudson Simpson Signed (1) The employer does not elect the employers’ liability coverage. James Simpson jaybirdsimpson40@aol.com Owner Des Moines Polk Iowa Regan Simpson Hudson Simpson Signed
2111 2024-03-21 14:28 Anonymous (not verified) 94.188.205.168 James Watson Limited Liability Company 4708 71st Street Urbandale, 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. 2024-03-24 James Edward watson junior99@email.com Urbandale IA United States Susie Givant Doug Frame Signed (1) The employer does not elect the employers’ liability coverage. Jason Lantz jason@lantzelite.com Employer Urbandale IA United States Susie Givant Doug Frame Signed
1199 2022-07-11 16:28 Anonymous (not verified) 166.222.225.181 Myriad Global Business Solutions Proprietorship 8016 Brooks Loop I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-11 James Eugene Hasquet, III Jay.Hasquet@Outlook.com Spearfish South Dakota United States Kent Orfield Kyle Padget Signed (1) The employer does not elect the employers’ liability coverage. James Eugene Hasquet, III Jay.Hasquet@Outlook.com Self Spearfish South Dakota United States Kent Orfield Kyle Padget Signed
107 2020-03-31 10:47 Anonymous (not verified) 209.152.77.101 Bart Fuller & James Fuller DBA Fuller & Sons Partnership 1302 Lincoln ST., Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-31 James Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Janice Henningsen Louise Helmke Signed (1) The employer does not elect the employers’ liability coverage. James Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Janice Henningsen Louise Helmke Signed
462 2021-04-06 08:56 Anonymous (not verified) 209.152.77.101 Bart Fuller & James Fuller DBA Fuller & Sons Partnership 1302 Lincoln ST., Ruthven,IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-06 James Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. James Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed
976 2022-03-15 10:44 Anonymous (not verified) 209.152.77.101 Bart Fuller & James Fuller DBA Fuller & Sons Partnership 1302 Lincoln ST., Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-15 James Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. James Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed
1517 2023-03-14 09:06 Anonymous (not verified) 94.188.207.230 Bart Fuller & James Fuller DBA Fuller & Sons Partnership 1302 Lincoln ST., Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-14 James Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. James Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed
2141 2024-04-09 09:34 Anonymous (not verified) 94.188.205.177 Bart Fuller & James Fuller DBA Fuller & Sons Partnership 1302 Lincoln Street Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-09 James Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Kathryn Kelley Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. James Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Kathryn Kelley Janice Henningsen Signed
2142 2024-04-09 09:39 Anonymous (not verified) 94.188.205.167 Bart Fuller & james Fuller DBA Fuller & Sons Partnership 1302 Lincoln Street Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-09 James Fuller goffins@ruthventel.com Ruthven Pal Alto Iowa Kathryn Kelley Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. James Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Kathryn Kelley Janice Henningsen Signed
1212 2022-07-19 10:15 Anonymous (not verified) 174.209.40.210 James holmes Proprietorship 866 40th Ave bettendorf IA 52722 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-19 James holmes jrholmes1958@gmail.com Moline Rock island Il Tiffani branham Cody dunbar Signed (1) The employer does not elect the employers’ liability coverage. Leaffilter north llc cdunbar@leaffilter.com Install manager Bettendorf Scott Ia Cody dunbar Tiffani branham Signed
772 2021-11-23 10:13 Anonymous (not verified) 63.229.189.35 Hubbards Cupboards Proprietorship 713 2nd Ave SW, Spencer, IA 51301-5603 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-23 James Hubbard abigail@rickmilesartisans.com Spencer Clay Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. James Hubbard abigail@rickmilesartisans.com Self Spencer Clay Iowa Abigail Miles Alex Miles Signed
1222 2022-07-21 16:01 Anonymous (not verified) 66.129.208.246 James J Stallman Proprietorship 190 BLUFF DR, Fairfax, IA 52228 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-21 James J Stallman stallmanjim@aol.com FAIRFAX IA United States James J Stallman James J Stallman Signed (1) The employer does not elect the employers’ liability coverage. Lundahl, Hatt, Austad Tax Services Inc NN@LHAtax.com President Marion Linn IA James J Stallman James J Stallman Signed
719 2021-11-05 13:48 Anonymous (not verified) 174.198.66.202 James Johnson Ace Floor Guys Proprietorship 521 29th st NE Cedar Rapids, Ia 52402 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-13 James Johnson acefloorguysia@gmail.com Cedar Rapids Linn Iowa Sarah Coberley Heather Howell Signed (1) The employer does not elect the employers’ liability coverage. James Johnson acefloorguysia@gmail.com Self Employed Cedar Rapids Linn Iowa Heather Howell Sarah Coberley Signed
1618 2023-04-28 11:10 Anonymous (not verified) 94.188.205.167 Hunter Flying Service, LLC Limited Liability Company PO Box 215 Hunter, AR 72074 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-28 James Lynn Cary hunterflying@att.net Hunter Woodruff Arkansas Karen Gifford Jason White Signed (1) The employer does not elect the employers’ liability coverage. James Lynn Cary hunterflying@att.net Self Hunter Woodruff AR Karen Gifford Jason White Signed
956 2022-03-08 13:56 Anonymous (not verified) 72.13.16.196 Naprstek Media LLC Limited Liability Company 6505 Wellington Ln, Dubuque, IA 52003 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-08 James Naprstek jimmy@kodiakcreative.com Dubuque Dubuque Iowa Trent Hanselmann Jonathan O'Brien Signed (1) The employer does not elect the employers’ liability coverage. Cheyenne Moseley services@e.legazoom.com Authorized Agent Glendale Los Angeles CA Trent Hanselmann Jonathan O'Brien Signed
303 2020-10-31 13:11 Anonymous (not verified) 173.17.230.149 Absolute Construction Limited Liability Partnership 135 main street, Carlisle, IA 50047 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-31 James Nelson jamesnelson1983@gmail.com Carlisle Warren Iowa Joe Simpson Alex Vanderbeek Signed (1) The employer does not elect the employers’ liability coverage. James Nelson jamesnelson1983@gmail.com self Carlisle Warren Iowa Joe Simpson Alex Vanderbeek Signed
437 2021-03-16 18:31 Anonymous (not verified) 38.121.121.16 Thompsen Irrigation Proprietorship 16086 Missouri Ave Crescent IA 51526 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-17 James R Thompsen jthom76285@aol.com Crescent Pottawattamie Iowa Mike Harmon Ilene Harmon Signed (1) The employer does not elect the employers’ liability coverage. James R Thompsen jthom76285@aol.com self Crescent Pottawattamie Iowa Mike Harmon Ilene Harmon Signed
784 2021-12-09 09:03 Anonymous (not verified) 97.64.139.42 JZ INC Limited Liability Company 2509 Ne 10th CT Grimes Iowa 50111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-08 James Scott Zastrow Zastrow74@gmail.com Grimes IA United States NIcole Zastrow Kevan Wiggins Signed (1) The employer does not elect the employers’ liability coverage. James scott Zastrow loffredon@aol.com Self Grimes IA United States nicole zastrow Kevan wiggins Signed
1666 2023-05-28 15:57 Anonymous (not verified) 94.188.207.223 Projects Under Development LLC Limited Liability Company 2516 Hickory Grove Rd Davenport Iowa 52804 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-29 James Stock jamese1053@gmail.com Davenport Scott Ia Ronald Lang Karen Walker Signed (1) The employer does not elect the employers’ liability coverage. James Stock jamese1053@gmail.com Owner Davenport Scott Ia Ronald Lang Karen Walker Signed
1668 2023-05-30 10:50 Anonymous (not verified) 94.188.207.230 Projects Under Development LLC Limited Liability Company 2516 Hickory Grove Rd Davenport Iowa 52804 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-30 James Stock jamese1053@gmail.com Davenport Scott Iowa Ronald Lang Karen Stock Signed (1) The employer does not elect the employers’ liability coverage. James Stock jamese1053@gmail.com Owener Davenport Scott Iowa Ronald Lang Karen Walker Signed
1669 2023-05-30 11:05 Anonymous (not verified) 94.188.207.225 Projects Under Development LLC Limited Liability Company 2516 Hickory Grove Rd Davenport IA 52804 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-30 James Stock jamese1053@gmail.com Davenport Scott Ia Ronald Lang Karen Walker Signed (1) The employer does not elect the employers’ liability coverage. James Stock jamese1053@gmail.com Owner Davenport Scott l Ia Ronald Lang Karen Walker Signed
1700 2023-06-22 14:53 Anonymous (not verified) 94.188.205.166 James Trotter Limited Liability Company 1341 Cachelin Dr Carter Lake IA 51510 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 James Trotter trotterwizard@gmail.com Carter Lake Pottawattamie IA Shelby Schultz Elora Trotter Signed (1) The employer does not elect the employers’ liability coverage. James Trotter trotterwizard@gmail.com Self Carter Lake Pottawattamie IA Shelby Schultz Elora Trotter Signed
1701 2023-06-22 15:03 Anonymous (not verified) 94.188.207.228 Midwest Teleworks Limited Liability Company 1341 Cachelin Dr Carter Lake IA 51510 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 James Trotter trotterwizard@gmail.com Carter Lake Pottawattamie IA Shelby Schultz Elora Trotter Signed (1) The employer does not elect the employers’ liability coverage. James Trotter trotterwizard@gmail.com Owner Carter Lake Pottawattamie IA Shelby Schultz Elora Trotter Signed
1076 2022-04-28 13:14 Anonymous (not verified) 149.20.212.228 Van Ginkel Farms LLC Limited Liability Company 2745 Chestnut Ave Inwood, IA 51240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-14 James Van Ginkel bonnievanginkel@gmail.com Inwood Lyon Iowa Jesse Niemeyer Jaslyn VanOtterloo Signed (1) The employer does not elect the employers’ liability coverage. James VanGinkel bonnievanginkel@gmail.com self Inwood Lyon Iowa Jesse Niemeyer Jaslyn VanOtterloo Signed
1914 2023-11-20 16:05 Anonymous (not verified) 94.188.207.227 Dark Horse Transport LLC Limited Liability Company 301 Lincoln St, Brayton, IA 50042 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-20 James William Meese bethany.dhtllc@gmail.com Brayton Audubon Iowa Hayley Meese-Cherry Wyatt Jessen Signed (1) The employer does not elect the employers’ liability coverage. James Wiliam Meese bethany.dhtllc@gmail.com Owner Brayton Audubon Iowa Hayley Meese-Cherry Wyatt Jessen Signed
2062 2024-02-29 08:25 Anonymous (not verified) 94.188.205.169 Midwest Splicing LLC Limited Liability Company 1803 N HALF BANK RD , Stringtown , OK 74569 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-29 James Xiong midwestsplicing71@yahoo.com Stringtown OKLAHOMA OKLAHOMA Vang Pao Chang Xia Vang Signed (1) The employer does not elect the employers’ liability coverage. James Xiong midwestsplicing71@yahoo.com owner STRINGTOWN Oklahoma Oklahoma xia Vang Vang Pao Chang Signed
730 2021-11-08 14:58 Anonymous (not verified) 97.64.139.42 JZ INC Limited Liability Company 2509 Ne 10th CT Grimes Iowa 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. 2022-11-08 James Zastrow Zastrow74@gmail.com Grimes Iowa United States Kevan Wiggins Jeremy Holmes Signed (1) The employer does not elect the employers’ liability coverage. James Zastrow zastrow74@gmail.com Self grimes polk iowa Kevan Wiggins Jeremy Holmes Signed
1239 2022-08-02 10:53 Anonymous (not verified) 184.80.177.137 Jamie Ingle, DBA Jamie's Little Sunflowers Proprietorship 7155 Columbus St - New Vienna, IA 52065 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-02 Jamie Ingle jheims@english-insurance.com Dyersville 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 Iowa Derrick Parsons Joyce Heims Signed
1774 2023-08-03 08:40 Anonymous (not verified) 94.188.205.168 J P Trucking, Inc. Proprietorship 8768 White Tail Lane, Dubuque, IA 52003 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-03 Jamison Noel jptrucking.jamison@gmail.com Dubuque DBQ Iowa Lindsay Noel Andy Kemp Signed (1) The employer does not elect the employers’ liability coverage. Jamison Noel jptrucking.jamison@gmail.com Owner Dubuque Dubuque Iowa Lindsay Noel Andy Kemp Signed
1037 2022-04-07 08:16 Anonymous (not verified) 104.207.27.18 SION LUTHERAN CHURCH Proprietorship 4525 FINCH AVE LAKE MILLS, IA 50450 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-07 JANE BRUNSVOLD janebrunsvold@yahoo.com LAKE MILLS WINNEBAGO IOWA ANDREW STENSRUD JILL FLUGUM Signed (1) The employer does not elect the employers’ liability coverage. ANDREW STENSRUD ANDREW@STENSRUDINSURANCE.COM INSURANCE AGENT LAKE MILLS WINNEBAGO IOWA JANE BRUNSVOLD JILL FLUGUM Signed
122 2020-04-15 18:10 Anonymous (not verified) 136.37.174.39 Merge Midwest Engineering, LLC Limited Liability Company 2668 W. Catalpa Street, Olathe, KS 66061 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-15 Janelle Marie Clayton jclayton@mergemidwest.com Olathe Johnson Kansas David Jahner Patrick McCartney Signed (1) The employer does not elect the employers’ liability coverage. Janelle Marie Clayton jclayton@mergemidwest.com Self Olathe Johnson Kansas David Jahner Patrick McCartney Signed
475 2021-04-13 19:19 Anonymous (not verified) 173.31.147.225 COAST TO COAST MILLWRIGHT LLC Limited Liability Company 2909 HWY 71 AND 9 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-05 JANIE CANTU JOEL@WALKERINSURANCEIA.COM SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The employer does not elect the employers’ liability coverage. JANIE CANTU janiecantu433@outlook.com SELF SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
2183 2024-04-26 14:49 Anonymous (not verified) 94.188.205.168 Cory's Painting LLC Limited Liability Company Po Box 1161 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Jared Birkenholz jareddrewb@gmail.com CEDAR FALLS IA United States Colton Blue Kari Houle Signed (1) The employer does not elect the employers’ liability coverage. Cory Koger coryspainting@gmail.com Self CEDAR FALLS IA United States Colton Blue Kari Houle Signed
1682 2023-06-08 17:55 Anonymous (not verified) 94.188.205.174 Jared hoffman Proprietorship 22429 250th st carroll IA 5140q I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-06 Jared Hoffman jhoffman@live.com Carroll Carroll Iowa Jeff dentlinger Brian babb Signed (1) The employer does not elect the employers’ liability coverage. Jared Hoffman jhoffman@live.com Self Carroll Carroll Iowa Jeff dentlinger Brian babb Signed
798 2021-12-15 08:03 Anonymous (not verified) 173.22.84.26 LAMPE APPLIANCE SERVICE, Inc Proprietorship 210 29TH ST 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. 2021-12-15 Jared J Lampe lampeappliance@gmail.com CEDAR RAPIDS Linn IA Douglas James Lampe John Kenneth Lampe Signed (1) The employer does not elect the employers’ liability coverage. Douglas James Lampe lampeappliance@gmail.com Vice President CEDAR RAPIDS Linn Iowa Douglas James Lampe John Kenneth Lampe Signed
2190 2024-04-29 09:28 Anonymous (not verified) 94.188.205.168 JOHNSON OHANA LLC Limited Liability Company 145 GREENBRIER DR, 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. 2024-04-29 JARED JOHNSON KONAOHANAICE@GMAIL.COM BURINGTON DES MOINES IOWA MARCY KNAUSS MATTHEW RINKER Signed (1) The employer does not elect the employers’ liability coverage. MAGGIE JOHNSON KONAOHANAICE@GMAIL.COM PARTNER/SPOUSE BURLINGTON DES MOINES IOWA MARCY KNAUSS MATTHEW RINKER Signed
1815 2023-08-23 14:16 Anonymous (not verified) 94.188.207.228 JP Distribution, LLC Limited Liability Company 3738 Pine Rdg NE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-23 Jared Prelle jpdist2014@gmail.com North Liberty IA United States Linda Stien Dawn Franck Signed (1) The employer does not elect the employers’ liability coverage. Jared Prelle jpdist2014@gmail.com Owner North Liberty Johnson IA Linda Stien Dawn Franck Signed
966 2022-03-11 10:04 Anonymous (not verified) 173.19.189.168 Steger Siding & Construction Limited Liability Company 1020 25th Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-11 Jared Steger jared.steger@gmail.com Marion IA United States Jared Steger Jared Steger Signed (1) The employer does not elect the employers’ liability coverage. Jared Steger jared.steger@gmail.com self Marion IA United States Jared Steger Jared Steger Signed
1127 2022-05-25 18:12 Anonymous (not verified) 216.51.235.160 Midwest Excavation & Trucking LLC Limited Liability Company 21324 Spring Ave Clarksville, Ia 50670 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-25 Jared Stephen Ragsdale Midwest.excavation.llc@gmail.com Clarksville Butler Iowa Dave Johnson Patrick Lursen Signed (1) The employer does not elect the employers’ liability coverage. Jared Stephen Ragsdale Midwest.excavation.llc@gmail.com Myself Clarksville Butler Iowa Dave Johnson Patrick Lursen Signed
1192 2022-07-07 21:15 Anonymous (not verified) 174.242.226.74 Quelland Flooring Limited Liability Company P.O. Box 5, Van Meter, IA, 50261 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-07 Jared Tyler Quelland Jquelland@gmail.com Van Meter IA United States Denise Walters Madison Miller Signed (1) The employer does not elect the employers’ liability coverage. Jared Tyler Quelland Jquelland@gmail.com Self Van Meter IA United States Denise Walters Madison Mileer Signed
1562 2023-04-10 07:43 Anonymous (not verified) 94.188.205.174 JB Concrete and Construction Limited Liability Company 306 1st Ave N.W Dayton 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. 2023-04-10 JaredBerglund jaredberglund71@gmail.com Dayton Webster Iowa Travis Sonksen Chase Haman Signed (1) The employer does not elect the employers’ liability coverage. JaredBerglund jaredberglund71@gmail.com Owner Dayton Webster Iowa Travis Sonksen Chase Haman Signed
579 2021-07-20 12:37 Anonymous (not verified) 166.205.124.133 M&M HOME IMPROVEMENT Limited Liability Company 5406 28th Ave. Moline , IL 61265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-07-20 Jarred Alexander bookkyddjay@gmail.com Moline USA IL Jacob Nagel Jacob Nagel Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jarred Alexander bookkyddjay@gmail.com Same Moline USA IL Jacob Nagel Jacob Nagel Signed
401 2021-02-15 14:50 Anonymous (not verified) 66.188.136.150 Jarrod Wernimont Proprietorship 24 Blackhawk Rd. Hanover, IL 61041 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-12 Jarrod Wernimont kschumacher@tricorinsurance.com Hanover Jo Daviess IL Russell Masartis Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Jarrod Wernimont kschumacher@tricorinsurance.com Same Hanover Jo Daviess IL Russell Masartis Shuree Behr Signed
1560 2023-04-07 11:47 Anonymous (not verified) 94.188.205.174 Art Deco Tile and Stone Limited Liability Company 4615 94th Pl Urbandale, IA 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-07 Jasmin Musinovic edin@artdecotileandstone.com Urbandale Polk Iowa Rick Wyant Todd Wyant Signed (1) The employer does not elect the employers’ liability coverage. Jasmin Musinovic edin@artdecotileandstone.com Self Urbandale Polk Iowa Rick Wyant Todd Wyant Signed
564 2021-07-08 13:33 Anonymous (not verified) 173.31.156.49 SS Docks Limited Liability Company P.O. Box 561 Okoboji IA 51355-0561 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-07-08 Jason Andrew Snow snowjas75@gmail.com Lake Park Dickinson IA Amber Egesdal Vickie Walters Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. SS Docks snowjas75@gmail.com Owner Okoboji Dickinson IA Amber Egesdal Vickie Walters Signed
955 2022-03-08 11:21 Anonymous (not verified) 166.181.80.171 JB Roofing & Home Repair Limited Liability Company 453 South Street Kalona, 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. 2022-03-08 Jason Boller jbroofhr@gmail.com Kalona Washington IA Jodee Stransky Christian Swartzentruber Signed (1) The employer does not elect the employers’ liability coverage. Christian Swartzentruber christian@fisherins.com Insurance Agent Kalona Washington IA Jodee Stransky Christian Swartzentruber Signed
1128 2022-05-26 11:11 Anonymous (not verified) 174.213.144.187 Leaf Filter Limited Liability Company 3060 se grimes blvd suite 100-300 Grimes iowa 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. 2022-05-24 Jason charlet jasonstreeservice2014@gmail.com Minburn Dallas Iowa Kami lillibridge Dale charlet Signed (1) The employer does not elect the employers’ liability coverage. N/a jasoncharlet703@gmail.com N/a N/a N/a N/a N/a N/a Signed
341 2020-12-23 08:52 Anonymous (not verified) 174.243.82.219 Jason D Struchen Proprietorship 1778 210th St Webster City, IA 50595 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-23 Jason David Struchen steruchen75@gmail.com Webster City Hamilton Iowa NA NA Signed (1) The employer does not elect the employers’ liability coverage. Jason D Struchen struchen75@gmail.com Same Webster City Hamilton Iowa NA NA 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
1902 2023-11-10 08:45 Anonymous (not verified) 94.188.207.226 Huff Construction LLC Limited Liability Company 1309 Business 30 Sw, Mount Vernon, IA 52314 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-10 Jason Huff huff.jasonm@gmail.com Mount Vernon IA United States Katie Huff Van Huff Signed (1) The employer does not elect the employers’ liability coverage. Jason Huff huff.jasonm@gmail.com Owner Mount Vernon IA United States Katie Huff Van Huff Signed
1325 2022-10-02 20:07 Anonymous (not verified) 50.80.107.101 Hanson Custom Cleanup and Removal LLC Limited Liability Company 1221 Fleur Dr. Waterloo, IA 50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-02 Jason Jacob Hanson jasonhanson1985@gmail.com Waterloo Blackhawk Iowa Cindy Shreve Jacob Ring Signed (1) The employer does not elect the employers’ liability coverage. Jason Hanson jasonhanson1985@gmail.com Self Waterloo Blackhawk Iowa Cindy Shreve Jacob Ring Signed
2030 2024-02-07 10:10 Anonymous (not verified) 94.188.207.227 Jason Jacobs Proprietorship 115 West 7th St., Suite 1W, Spencer, IA 51301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-07 Jason Jacobs jason.jacobs@thrivent.com Spencer Clay Iowa Brad Bernardy Emily Jacobs Signed (1) The employer does not elect the employers’ liability coverage. Jason Jacobs jason.jacobs@thrivent.com Self Spencer Clay Iowa Brad Bernardy Emily Jacobs Signed
1413 2023-01-06 15:15 Anonymous (not verified) 199.120.121.97 Jason Gaul Proprietorship 1088 Ridge Lane Harlan, IA 51537 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-06 Jason Robert Gaul gauljasonr@gmail.com Harlan Shelby Iowa Haley Leinen Scott Leinen Signed (1) The employer does not elect the employers’ liability coverage. Jason Robert Gaul gauljasonr@gmail.com Self Harlan Shelby Iowa Haley Leinen Scott Leinen Signed
568 2021-07-09 09:26 Anonymous (not verified) 184.12.14.229 SS Docks LLC Limited Liability Company P.O. Box 561 Okoboji, IA 51355-0561 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-05-21 Jason Snow k.kooima@q.com Okoboji Dickinson Iowa Mabel Behnke Brandi Parks Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jason Snow - SS Docks LLC k.kooima@q.com Owner Okoboji Dickinson Iowa Mabel Behnke Brandi Parks Signed
570 2021-07-09 16:42 Anonymous (not verified) 184.12.14.229 SS Docks LLC Limited Liability Company P.O. Box 561 Okoboji, IA 51355-0561 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-05-21 Jason Snow kkooima@q.com Okoboji Dickinson Iowa Mabel Behnke Brandi Parks Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jason Snow - SS Docks LLC kkooima@q.com Owner Okoboji Dickinson Iowa Mabel Behnke Brandi Parks Signed
593 2021-08-03 12:29 Anonymous (not verified) 184.12.14.229 SS Docks LLC Limited Liability Company PO Box 561, Okoboji, IA 51355-0561 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-05-21 Jason Snow k.kooima@q.com Okoboji Dickinson Iowa Mabel Behnke Brandi Parks Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jason Snow - SS Docks LLC k.kooima@q.com Owner Okoboji Dickinson Iowa Mabel Behnke Brandi Parks Signed
454 2021-03-26 09:46 Anonymous (not verified) 50.82.130.211 Jason Thoren Proprietorship 104 1st Street NW, Tripoli, IA 50676 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-04 Jason Thoren cmins_re@mchsi.com Tripoli Bremer Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Jason Thoren cmins_re@mchsi.com Self Tripoli Bremer Iowa Chad Campbell Roxanne Kolder Signed
2101 2024-03-18 09:21 Anonymous (not verified) 94.188.205.166 Jason Tindle Proprietorship 4103 1st St. Des Moines, Ia 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-18 Jason Tindle jtconstruction93@yahoo.com DES MOINES IOWA United States Zach Miller Nick Soma Signed (1) The employer does not elect the employers’ liability coverage. Jason Tindle jtconstruction93@yahoo.com Myself Same Same Same Same Same Signed
1664 2023-05-25 13:18 Anonymous (not verified) 94.188.207.227 Jason Vreeman Proprietorship 5571 170th St sibley Ia I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-25 Jason Vreeman jvreeman21@gmail.com Sibley Osceola IA Katie Vreeman Jerry vreeman Signed (1) The employer does not elect the employers’ liability coverage. Jason Vreeman jvreeman21@gmail.com Self Sibley Osceola IA Katie Vreeman Jerry vreeman Signed
270 2020-09-25 10:14 Anonymous (not verified) 174.243.97.206 J Watts Electric Limited Liability Company 615 E 2nd St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-25 Jason Watts jason.watts@jwattselectric.com Webster City Hamilton Iowa Eli Ochoa Cody Ewing Signed (1) The employer does not elect the employers’ liability coverage. Jason Watts jason.watts@jwattselectric.com Self Webster City Hamilton Iowa Eli Ochoa Cody Ewing Signed
241 2020-08-23 16:10 Anonymous (not verified) 67.45.96.12 Wellik & Sons, LLC Limited Liability Company 1770 HWY 18, Garner, IA 50438 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-23 Jason Yon Juenger j420money@yahoo.com Garner Hancock Iowa Joshua P Wellik Ashley S Wellik Signed (1) The employer does not elect the employers’ liability coverage. Joshua Paul Wellik wellikandsons@gmail.com subcontractor Garner Hancock Iowa Joshua Paul Wellik Ashley S Wellik Signed
1692 2023-06-15 15:20 Anonymous (not verified) 94.188.207.228 Javier Rodriguez Proprietorship 1512 18th St Des Moines, Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-14 Javier A Rodriguez R.Javier14@gmail.com Des Moines Polk Iowa Kelly Denger Debra Stratton Signed (1) The employer does not elect the employers’ liability coverage. Javier A Rodriguez R.Javier14@gmail.com self Des Moines Polk Iowa Kelly Denger Debra Stratton Signed
1120 2022-05-19 09:49 Anonymous (not verified) 65.125.92.130 JG Landscaping, LLC Limited Liability Company 317 E 23rd St. Des Moines, IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-19 Javier Alexander Guzman alexguz76@outlook.com Des Moines Polk IA Brenda Reedy Chad Smith Signed (1) The employer does not elect the employers’ liability coverage. Javier Alexander Guzman alexguz76@outlook.com Self Des Moines Polk IA Brenda Reedy Chad Smith Signed
470 2021-04-13 09:34 Anonymous (not verified) 173.21.135.56 JNZ Recruiting LLC Limited Liability Company 703 Washington St. Williamsburg, IA 52361 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-04-07 Javier Nevarez amanda@burginsuranceagency.com Williamsburg IA IA Amanda Clubb Bradley Schaefer Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Javier Nevarez amanda@burginsuranceagency.com Self Williamsburg Iowa Iowa Amanda Clubb Bradley Schaefer Signed
931 2022-02-21 15:04 Anonymous (not verified) 69.18.14.11 Lawn's Plus Proprietorship 6082 Northwest Beaver Drive, Johnston, Iowa 50131, United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-01 Javier Nieto jacobanderson55@yahoo.com Des Moines Polk Iowa Jacob Anderson Andrea Nieto Signed (1) The employer does not elect the employers’ liability coverage. Javier Nieto jacobanderson55@yahoo.com Self Des Moiens Polk Iowa Jacob Anderson Andrea Nieto Signed
1573 2023-04-14 13:43 Anonymous (not verified) 94.188.205.167 Jaxon Kressley Proprietorship 954 Boston Way, #12, Corralville, 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. 2023-04-14 Jaxon Kressley jaxon@optionsexteriors.com Corralville Johnson Iowa Charlotte Rasmussen Austin Miller Signed (1) The employer does not elect the employers’ liability coverage. Jaxon Kressley jaxon@optionsexteriors.com Owner/Self Corralville Johnson Iowa Charlotte Rasmussen Austin Miller Signed
124 2020-04-16 12:07 Anonymous (not verified) 96.3.180.122 Gold Rush, LLC Limited Liability Company 1395 130TH 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. 2020-04-16 Jay Christopher Morrow jcmorrow2@hotmail.com WAYLAND Henry IAUS chad mitchell Jonathan Mitchell Signed (1) The employer does not elect the employers’ liability coverage. Gold Rush, LLC jcmorrow2@gmail.com Self WAYLAND Henry IAUS chad mitchell Jonathan Mitchell Signed
406 2021-02-18 10:41 Anonymous (not verified) 165.225.61.119 Romeo Painitng Proprietorship 7 Waverly Dr Rock Island, IL 61201 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-18 Jay Romeo jay.romeo12@yahoo.com Rock Island Rock Island IL Seth Rowland Ryan Myers Signed (1) The employer does not elect the employers’ liability coverage. Jay Romeo jay.romeo12@yahoo.com Self Rock island Rock Island IL Seth Rowland Ryan Myers Signed
725 2021-11-05 14:32 Anonymous (not verified) 174.198.66.202 Jay Schulte Proprietorship 7530 Prairie Hawk Dr Sw, Cedar Rapids, Ia 52404 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-15 Jay Schulte schultejay@Hotmail.com Cedar Rapids Linn Iowa Heather Howell Sarah Coberley Signed (1) The employer does not elect the employers’ liability coverage. Jay Schulte schultejay@hotmail.com Self Employed Cedar Rapids Linn Ia Sarah Coberley Heather Howell Signed
629 2021-09-01 09:44 Anonymous (not verified) 204.155.61.217 Thrapp Electric Proprietorship 708 2nd Street Wellman, Iowa 52356 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-01 Jay Thrapp socketman5555@hotmail.com Wellman Washington Iowa Jeffrey Spenner Shawn Powell Signed (1) The employer does not elect the employers’ liability coverage. Jay Thrapp socketman5555@hotmail.com Owner Wellman Washington Iowa Jeffrey Spenner Shawn Powell Signed
1931 2023-12-01 18:01 Anonymous (not verified) 94.188.207.225 Jay Wang Limited Liability Company 16672 Verona Hills Dr, 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. 2023-12-01 Jay Wang jaywang@wasabidsm.com Clive US IA WenHui chen Yingna Zheng Signed (1) The employer does not elect the employers’ liability coverage. Jay Wang Jaywang@wasabidsm.com Self Clive US IA WenHui Chen Yingna Zheng Signed
1935 2023-12-02 18:34 Anonymous (not verified) 94.188.207.229 Wasabi Johnston LLC Limited Liability Company 8184 Birchwood Ct, Johnston IA 50131 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-02 Jay Wang jaywang@wasabidsm.com Clive Dallas IA Engjin zheng yingna Zheng Signed (1) The employer does not elect the employers’ liability coverage. Jay Wang jaywang@wasabidsm.com self Clive Dallas IA Wenhui Cheng Enjing Zheng Signed
1984 2024-01-15 17:33 Anonymous (not verified) 94.188.207.227 Jay Wang Limited Liability Company 8481 Birchwood Ct, Johnston I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-15 Jay Wang jaywang@wasabidsm.com Clive US IA Yingna Zheng Qiaoqiao Li Signed (1) The employer does not elect the employers’ liability coverage. Jay Wang jaywang@wasabidsm.com Self Clive US IA Yingna Zheng Qiaoqiao Li Signed
2003 2024-01-28 12:38 Anonymous (not verified) 94.188.205.169 Wasabi Urbandale LLC Limited Liability Company 2301 Rocklyn Dr, Urbandale IA 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-01 Jay Wang jaywang@wasabidsm.com Clive Dallas IA Ajdin Nadarich Jeremy Boysen Signed (1) The employer does not elect the employers’ liability coverage. Jay Wang jaywang@wasabidsm.com Self Clive Dallas IA Lisa Lee Yingna Zheng Signed
1020 2022-03-29 16:53 Anonymous (not verified) 207.32.60.144 J.A. Dahlhauser, Ltd. Proprietorship 1741 Hwy. 7 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-29 Jaylin A. Dahlhauser jaydahlhauser@gmail.com Newell IA United States Matthew McClellan Gracelin R. Dahlhauser Signed (1) The employer does not elect the employers’ liability coverage. Jaylin A. DAhlhauser jaydahlhauser@gmail.com Owner Newell IA United States Matthew McClellan Gracelin R. Dahlhauser Signed
635 2021-09-10 13:41 Anonymous (not verified) 166.181.84.226 JZH Roofing Specialists LLC Limited Liability Company 2127 Swan Dr, Norwalk, Iowa. 50211 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-10 Jayme Alexander Christian Heiselman wrkhrd2plyhrd04@gmail.com Norwalk Warren Iowa Melanie Handy Jesse Hagge Signed (1) The employer does not elect the employers’ liability coverage. Jayme Alexander Christian Heiselman wrkhrd2plyhrd04@gmail.com Single member Norwalk Warren Iowa Melanie Handy Jesse Hagge Signed
869 2022-01-28 15:28 Anonymous (not verified) 63.229.189.35 Jones Painting Proprietorship PO box 523, Okoboji, IA 51355 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-28 JD Jones abigail@rickmilesartisans.com Okoboji Dickinson Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. JD Jones abigail@rickmilesartisans.com Self Okoboji Dickinson Iowa Abigail Miles Alex Miles Signed
1107 2022-05-16 15:28 Anonymous (not verified) 64.33.230.163 hangar 8 spray service Limited Liability Company 1626 airport dr I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-16 jed douglas hansen hangar.8@hotmail.com Clark South Dakota United States jed douglas hansen jed douglas hansen Signed (1) The employer does not elect the employers’ liability coverage. jed douglas hansen hangar.8@hotmail.com contract Clark South Dakota United States Jed Hansen Jed Hansen Signed
1110 2022-05-17 11:17 Anonymous (not verified) 64.33.230.163 Jed Hansen Proprietorship 1626 Airport Dr I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-17 Jed Douglas Hansen hangar.8@hotmail.com Clark Clark South Dakota Jed Hansen Jed Hansen Signed (1) The employer does not elect the employers’ liability coverage. Jed Hansen hangar.8@hotmail.com Proprietor Clark Clark South Dakota Jed Hansen Jed Hansen Signed
1111 2022-05-17 11:18 Anonymous (not verified) 64.33.230.163 Jed Hansen Proprietorship 1626 Airport Dr I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-17 Jed Douglas Hansen hangar.8@hotmail.com Clark Clark South Dakota Jed Hansen Jed Hansen Signed (1) The employer does not elect the employers’ liability coverage. Jed Hansen hangar.8@hotmail.com Proprietor Clark Clark South Dakota Jed Hansen Jed Hansen Signed
1506 2023-03-08 15:12 Anonymous (not verified) 94.188.207.226 Heritage Towing LLC Limited Liability Company 404 Sherman Ave. Ackley Iowa 50601 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-08 Jeff Brass heritagemotors17@yahoo.com Ackley Hardin Iowa Joellen Reynolds Linzie Morris Signed (1) The employer does not elect the employers’ liability coverage. Jeff Brass hertiagemotors17@yahoo.com Member of LLC Ackley Hardin Iowa JoEllen Reynolds Linzie Morris Signed
512 2021-05-11 13:12 Anonymous (not verified) 173.31.147.225 RUTHVEN ROCKS LLC Limited Liability Company 1205 ROLLING ST RUTHVEN IOWA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-11 JEFF CACEK JEFF@RUTHVENROCKS.COM RUTHVEN PALO ALTO IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. JEFF CACEK joel@walkerinsuranceia.com MEMBER RUTHVEN PALO ALTO IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
769 2021-11-22 17:13 Anonymous (not verified) 63.229.189.35 Jeff Johnson Proprietorship 3114 Keokuk Ave, Spirit Lake, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-22 Jeff Johnson juliejeff1994@yahoo.com Spirit Lake Dickinson Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Jeff Johnson abigail@rickmilesartisans.com Self SPIRIT LAKE Dickinson Iowa Abigail Miles Alex Miles Signed
336 2020-12-11 11:55 Anonymous (not verified) 173.16.197.72 A Metro Snow Removal And Lawn Care Limited Liability Company 6436 Washington Ave Windsor Heights, Iowa 50324 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-12-11 Jeff Lamp Sr. jeff.lamp79@gmail.com Windsor Height Polk Iowa Rick Brown Jill Fresh Signed (1) The employer does not elect the employers’ liability coverage. Jeff Lamp Sr. Jeff.lamp79@gmail.com Owner Windsor Heights Polk Iowa Rick Brown Jill Fresh Signed
2092 2024-03-13 12:55 Anonymous (not verified) 94.188.205.175 Banker's Lock and Safe Proprietorship 1914 Porter Ave Des Moines Iowa 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-13 Jeff Losee bankerslockandsafe@yahoo.com Des Moines Polk IA Jennifer D Losee Kendra D Losee Signed (1) The employer does not elect the employers’ liability coverage. Jeff Losee bankerslockandsafe@yahoo.com Owner Des Moines Iowa Polk IA Jennifer D Losee Kendra D Losee Signed
768 2021-11-22 16:53 Anonymous (not verified) 63.229.189.35 Jeff Luchtel Painting Proprietorship PO Box 225, Milford, IA 51351-0225 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-22 Jeff Luchtel jluchtel@gmail.com Milford Dickinson Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Jeff Luchtel abigail@rickmilesartisans.com Self SPIRIT LAKE Dickinson Iowa Abigail Miles Alex Miles Signed
311 2020-11-10 10:42 Anonymous (not verified) 75.162.206.98 Menz Construction, LCC Limited Liability Company 304 SW Clark Lane, Grimes, Iowa 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. 2020-11-10 Jeff Menz construction.menz@gmail.com Grimes Polk Iowa Janelle Menz Barb Menz Signed (1) The employer does not elect the employers’ liability coverage. David Finneseth david.finneseth@fbfs.com Agent Perry Dallas Iowa Janelle Menz Barb Menz Signed
1486 2023-02-26 17:53 Anonymous (not verified) 94.188.205.177 TURNER LAWN CARE Limited Liability Company 16493 185th Ave. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-27 JEFF TURNER jscturner2626@gmail.com MILO IA United States Tim Borrall BONNIE BORRALL Signed (1) The employer does not elect the employers’ liability coverage. SHARON RENEE TURNER jscturner2626@gmail.com wife MILO IA United States Tim Borrall BONNIE BORRALL Signed
1929 2023-11-30 10:46 Anonymous (not verified) 94.188.207.225 White Masonry, Inc. Proprietorship 15141 Bluff Trl., Carlisle, IA 50047 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-30 Jeff White whitemasonry1979@hotmail.com Carlisle IA IA Cathleen Marie White Sam Jeffrey White Signed (1) The employer does not elect the employers’ liability coverage. Jeffrey Dean White WHITEMASONRY1979@HOTMAIL.COM Self CARLISLE ia ia Cathleen Marie White Sam Jeffrey White Signed
802 2021-12-16 21:44 Anonymous (not verified) 98.21.205.195 Kustom Home Improvements Proprietorship 400 Davidson St New Virginia Iowa 50210 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-16 Jeffrey Allen Webster kustomhomeimprovements.dk@gmail.com New Virginia Warren Iowa Cindy Sue Gyles Shantell Christine Rice Signed (1) The employer does not elect the employers’ liability coverage. David Jack Kimmel kustomhomeimprovements.dk@gmail.com Self New Virginia Warren Iowa Cindy Sue Gyles Shantell Christine Rice Signed
440 2021-03-18 08:11 Anonymous (not verified) 66.188.136.150 Jeffrey Gardner Proprietorship 3020 W 1st St., Davenport, IA 52804 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-17 Jeffrey Gardner kschumacher@tricorinsurance.com Davenport Polk IA Russell Masartis Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Jeffrey Gardner kschumacher@tricorinsurance.com Same Davenport Polk IA Russell Masartis Shuree Behr Signed
344 2020-12-28 11:31 Anonymous (not verified) 173.31.147.225 JEFFREY GOETZINGER Proprietorship 2112 ITHACA AVE SPIRIT LAKE IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-12-22 JEFFREY GOETZINGER WALKERINSURANCE@MCHSI.COM SPIRIT LAKE DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. JEFFREY GOETZINGER WALKERINSURANCE@MCHSI.COM SELF SPIRIT LAKE DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
586 2021-07-26 08:37 Anonymous (not verified) 71.7.62.131 Jeffrey Knoot Proprietorship 1251 Illinois Dr. Knoxville IA, 50138-8862 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Jeffrey Jon Knoot opsisdental@gmail.com Knoxville Marion Iowa Sharon Kay Spriggs Lisa Michelle Dudley Signed (1) The employer does not elect the employers’ liability coverage. Jeffrey Jon Knoot opsisdental@gmail.com self Knoxville Marion Iowa Sharon Kay Spriggs Lisa Michelle Dudley Signed
2013 2024-01-31 15:14 Anonymous (not verified) 94.188.205.167 Aspen Ridge LLC Limited Liability Company 1404 G Ave Marengo, IA 52301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-10 Jeffrey McKusker jeff@mckuskerelectric.com Marengo Iowa Iowa Karly Kovar Jacob McKusker Signed (1) The employer does not elect the employers’ liability coverage. Lori McKusker jeff@mckuskerelectric.com Spouse Mead Weld Colorado Karly Kovar Jacob McKusker Signed
412 2021-02-23 14:23 Anonymous (not verified) 205.185.135.176 Jeffrey Meyer Proprietorship 118 1st St SE New Albin IA 52160 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-23 Jeffrey Meyer meyertimberservices@gmail.com New Albin Allamakee Iowa Michael Klug Kayla Snitker Signed (1) The employer does not elect the employers’ liability coverage. Michael Klug mike@aibme.com Insurance Agent Caledonia Houston Minnesota Jeffrey Meyer Kayla Snitker Signed
67 2020-02-19 10:16 Anonymous (not verified) 198.167.182.164 AWF579 LLC Limited Liability Company 13 Lynden Dr NE, Iowa City, IA 52240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-18 Jeffrey Schiltz jeffschiltz2@yahoo.com Iowa City Johnson Iowa Kyle Stahle Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Jeffrey Schiltz jeffschiltz2@yahoo.com Managing Member Iowa City Johnson Iowa Kyle Stahle Dyan Kriener Signed
205 2020-07-15 14:19 Anonymous (not verified) 108.209.12.64 Sequoia integrative Medical Services Limited Liability Company 1746 Paul Drive I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-15 Jennifer Christine VandenHeuvel jvandenheuvel@att.net Kaukauna WI United States David VandenHeuvel Pam Leplavy Signed (1) The employer does not elect the employers’ liability coverage. Jennifer Christine VandenHeuvel jvandenheuvel@att.net Owner Kaukauna WI United States David VandenHeuvel Pam Leplavy Signed
882 2022-02-02 11:09 Anonymous (not verified) 67.55.205.135 Tree & Forestry Equipment 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 Jennifer Hicks jennifer@treeandforestry.com Gowrie Webster Iowa Chad Hicks Caden Konecne Signed (1) The employer does not elect the employers’ liability coverage. Jennifer Hicks jennifer@treeandforestry.com self Gowrie Webster Iowa Chad Hicks Caden Konecne Signed
1680 2023-06-06 12:08 Anonymous (not verified) 94.188.205.168 Sipac Drywall Proprietorship 1130 Columbia St, Waterloo, IA 50703 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-06 Jennifer Sipac jenniferyoung164@gmail.com Waterloo Black Hawk Iowa Augie Ferguson Wendy Phillips Signed (1) The employer does not elect the employers’ liability coverage. Jennifer Sipac jenniferyoung164@gmail.com Owner Waterloo Black Hawk Iowa Augie Ferguson Wendy Phillips Signed
807 2021-12-20 09:30 Anonymous (not verified) 63.153.145.38 Jerry Ollerich Trucking Proprietorship 46884 267th Street Sioux Falls SD 57106 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-20 Jerald William Ollerich jeanollerich@yahoo.com Sioux Falls Minnehaha SD James K. Ollerich Joanne K. Berg Signed (1) The employer does not elect the employers’ liability coverage. Jean Staebell Ollerich jeanollerich@yahoo.com Wife/manager Sioux Falls Minnehaha SD James K. Ollerich Joanne K. Berg Signed
328 2020-11-26 12:28 Anonymous (not verified) 174.198.82.38 Duke millwright doing business as duke & sons Limited Liability Company 3264 e Payton ave 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. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2020-11-26 Jeremiah duke jpduke24.7.365@gmail.com Des Moines Polk county Iowa Daniel Patrick Hemann Nikki Marie Harvey Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Diana duke dukemillwright@gmail.com Self Des Moines Polk Iowa Nikki Marie Harvey Daniel Patrick Hemann Signed
722 2021-11-05 14:07 Anonymous (not verified) 209.252.172.87 Jeremiah Lunsford Proprietorship 624 Carroll Dr SE, Cedar Rapids, IA 52403 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-10 Jeremiah Lundsford jjaylunsford@gmail.com Cedar Paids Linn Iowa Heather Howell Sarah Coberley Signed (1) The employer does not elect the employers’ liability coverage. Jeremiah Lunsford jjaylunsford@gmail.com Self Employed Cedar Rapids Linn Iowa Sarah Coberley Heather Howell Signed
1071 2022-04-26 15:31 Anonymous (not verified) 63.152.69.47 Black squirrel siding llc Limited Liability Company 1512 n 1st Ave apt c203s coralville,ia52241 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-26 Jeremiah Petsche jpetsche44@gmail.com Coralville Johnson Iowa Jessica schimf Karl schimf Signed (1) The employer does not elect the employers’ liability coverage. Jeremiah petsche jpetsche44@gmail.com Myself Coralville Johnson Iowa Jessica schimf Karl schimf Signed
1954 2023-12-13 13:51 Anonymous (not verified) 94.188.207.227 Beeson Trucking LLC Limited Liability Company 219 Tilden St Kingsley IA 51028 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-13 Jeremy Beeson jeremy4k78@yahoo.com Kingsley Plymouth IA Katherine Weaver Darla Robley Signed (1) The employer does not elect the employers’ liability coverage. Jeremy Beeson jeremy4k78@yahoo.com Self Kingsley Plymouth IA Katherine Weaver Darla Robley Signed
499 2021-04-28 08:05 Anonymous (not verified) 167.142.98.81 Bents Consulting LLC Limited Liability Company 2147 160th Street Boone Iowa 50036 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-28 Jeremy D Bents help@bentsconsulting.com Boone Boone Iowa Derek Hanson Bob Clements Signed (1) The employer does not elect the employers’ liability coverage. Jeremy D Bents help@bentsconsulting.com Owner Boone Boone Iowa Derek Hanson Bob Clements Signed
1709 2023-06-26 14:55 Anonymous (not verified) 94.188.205.177 Jeremy Pledge Proprietorship 3310 East Washington Street, Iowa City, IA 52245 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-26 Jeremy Pledge worknoplay8@gmail.com Iowa City, IA Johnson County Iowa Jordan Nisiewicz Charles Wood Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay Missouri Charles Woods Jordan Loyd Signed
1537 2023-03-27 13:21 Anonymous (not verified) 94.188.207.228 miller hybrids Limited Liability Company 1213 Larch Ave, Kalona, IA 52247 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-01 Jeremy Wakerhauser jwakerhauser@gmail.com Sun Prairie WI United States Jeremy Wakerhauser Jeremy Wakerhauser Signed (1) The employer does not elect the employers’ liability coverage. Jeremy Wakerhauser jwakerhauser@gmail.com sole proprieter Sun Prairie WI United States Jeremy Wakerhauser Jeremy Wakerhauser Signed
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
304 2020-10-31 13:23 Anonymous (not verified) 173.17.230.149 Jerome Jones Proprietorship 5203 Douglas Avenue, Des Moines, IA 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-31 Jerome Jones jeromepops1@gmail.com Des Moines Polk IA Joe Simpson James Nelson Signed (1) The employer does not elect the employers’ liability coverage. Jerome Jones jeromepops1@gmail.com self Des Moines Polk IA Joe Simpson James Nelson Signed
258 2020-09-15 13:14 Anonymous (not verified) 50.83.182.140 Moyer Painting Proprietorship 934 Norwood Drive I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-15 jerome Moyer moyer_painting@live.com Norwalk IA United States Sally Moyer Adam Adams Signed (1) The employer does not elect the employers’ liability coverage. jerome b moyer moyer_painting@live.com Self norwalk IA United States sally moyer Adam Adams Signed
21 2020-01-01 18:16 Anonymous (not verified) 72.35.186.80 Jerry Arnold Proprietorship 1426 25th St, Humeston, IA 50123 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-01 Jerry Arnold LLArnold62@gmail.com Humeston Wayne Iowa Fred Throckmorton Joyce Throckmorton Signed (1) The employer does not elect the employers’ liability coverage. Jerry Arnold LLArnold62@gmail.com Self Humeston Wayne Iowa Fred Throckmorton Joyce Throckmorton Signed
1353 2022-10-31 21:35 Anonymous (not verified) 50.82.84.225 Jerry Bassett Proprietorship 108 NE 22 Cr I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-31 Jerry Bassett JerryDebBassett@aol.com GRIMES IA United States Deb Bassett Jerry Bassett Signed (1) The employer does not elect the employers’ liability coverage. Jerry Bassett JerryDebBassett@aol.com Self Grimes Polk Iowa Deb Bassett Jerry Bassett Signed
810 2021-12-22 15:13 Anonymous (not verified) 167.142.30.134 Bouillon Lawn Care Proprietorship 3074 Lodge Ave Greene, IA 50636 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-22 Jerry Bouillon greeneflowerman@yahoo.com Greene Floyd Iowa Lucas Wedeking Misty Osborn Signed (1) The employer does not elect the employers’ liability coverage. Jerry Bouillon Greeneflowerman@yahoo.com Self Greene Floyd Iowa Lucas Wedeking Misty Osborn Signed
1054 2022-04-15 15:05 Anonymous (not verified) 173.23.251.188 Integrity Design & Development, LLC Limited Liability Company 810 NW Logan 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. 2022-04-15 Jerry Houk integrity.design.development@gmail.com Ankeny Polk Iowa Tara Murphy Mike Ryerson Signed (1) The employer does not elect the employers’ liability coverage. Integrity Design & Development, LLC integrity.design.development@gmail.com owner Ankeny Polk Iowa Tara Murphy Mike Ryerson Signed
2162 2024-04-18 19:25 Anonymous (not verified) 94.188.205.177 Escobar Enterprises, LLC Limited Liability Company 125 East Broad Street, Des Moines, Iowa 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-18 Jesse Escobar jesse@escobar-enterprises.com Des Moines Polk Iowa Rene Mauricio Martinez Jessa Caitlin Marfal Signed (1) The employer does not elect the employers’ liability coverage. Jesse Escobar jesse@escobar-enterprises.com owner Des Moines Polk Iowa Rene Mauricio Martinez Jessa Caitlin Marfal Signed
945 2022-03-04 10:15 Anonymous (not verified) 97.125.39.88 Solid Solutions Caulking LLC. Limited Liability Company 1011 N. Ankeny Blvd P.O. Box 216. 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. 2022-03-04 Jesse Guilford sscaulking@yahoo.com Ankeny Polk Iowa Jesse Guilford Jade Guilford Signed (1) The employer does not elect the employers’ liability coverage. Jade Guilford sscaulking@yahoo.com Secratary Ankeny Polk Iowa Jesse Guilford Jade Guilford Signed
1419 2023-01-12 09:27 Anonymous (not verified) 71.34.173.44 Solid Solutions Caulking LLC. Limited Liability Company 1011 N. Ankeny BLVD Po Box 216 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. 2023-01-01 Jesse Guilford sscaulking@yahoo.com Ankeny Polk Iowa Jesse Guilford Jade Guilford Signed (1) The employer does not elect the employers’ liability coverage. Jesse Guilford sscaulking@yahoo.com Self Ankeny Polk Iowa Jesse Guilford Jade Guilford Signed
1397 2022-12-21 14:05 Anonymous (not verified) 50.81.162.60 Jesse Iseminger Proprietorship 3117 e 40th ct, Des Moines IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-21 Jesse Iseminger Jesseiseminger@gmail.com Des Moines Polk Iowa Shelly Johns Brad Weikert Signed (1) The employer does not elect the employers’ liability coverage. Jesse Iseminger Jesseiseminger@gmail.com Self Des Moines Iowa Iowa Shelly Johns Brad Weikert Signed
847 2022-01-20 13:54 Anonymous (not verified) 50.82.130.211 Albatross Capital, LLC Limited Liability Company 28003 290th Street, Parkersburg IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-22 Jesse Nitcher cmins_re@mchsi.com Parkersburg Butler IA Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Jesse Nitcher cmins_re@mchsi.com Member of LLC Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed
1124 2022-05-25 06:32 Anonymous (not verified) 69.77.219.67 J&T Dairy Cattle Company Proprietorship 1524 290th St. Inwood IA 51240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-25 Jesse T VanDeStroet inwoodfeeders@gmail.com Inwood Lyon IA Josh Tommeraus Nathan Van Der Wilt Signed (1) The employer does not elect the employers’ liability coverage. Jesse T VanDeStroet inwoodfeeders@gmail.com Owner Inwood Lyon Iowa Josh Tommeraus Nathan Van Der WIlt Signed
85 2020-03-09 08:17 Anonymous (not verified) 198.167.182.164 Simply Anchored LLC dba Simply Mae's Limited Liability Company 601 Broad St, Story City, IA 50248 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-05 Jessi Kettenacker jessi@simplymaes.com Story City Story Iowa Lynn McKinney Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Jessi Kettenacker jessi@simplymaes.com Managing Member Story City Story Iowa Lynn McKinney Dyan Kriener Signed
315 2020-11-13 10:48 Anonymous (not verified) 66.188.136.150 Jessie Spurlin Proprietorship 58977 Al Hwy 77, Talladega, AL 35160 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-11 Jessie Spurlin kschumacher@tricorinsurance.com Talladega Talladega AL Russell Masartis Nancy Wortley Signed (1) The employer does not elect the employers’ liability coverage. Jessie Spurlin kschumacher@tricorinsurance.com Same Talledaga Talledaga AL Russell Masartis Nancy Wortley Signed
1485 2023-02-25 18:14 Anonymous (not verified) 94.188.205.177 J&V painting Limited Liability Company 4759 woodland AV #56 West 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. 2023-02-25 Jessika Romero jony.bel.vla@gmail.com West Des Moines Polk Ia Samir rahmanovic Samir rahmanovic Signed (1) The employer does not elect the employers’ liability coverage. Jessika Romero jony.bel.vla@gmail.com Self West Des Moines Polk IA Samir Rahmanovic SAMIR RAHMANOVIC Signed
261 2020-09-17 15:52 Anonymous (not verified) 65.127.131.118 Jesus Adrian Martinez Proprietorship 1517 Searle St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-17 Jesus Adrian Martinez adrianmartinezventura21@gmail.com Des Moines Polk Iowa Brian Pruitt Martin Pinon Signed (1) The employer does not elect the employers’ liability coverage. Jesus Adrian Martinez adrianmarinezventura21@gmail.com self Des Moines Polk Iowa Brian Pruitt Martin Pinon Signed
1608 2023-04-26 11:51 Anonymous (not verified) 94.188.205.167 Jesus Lozano Proprietorship 1334 E 16th st Des Moines Iowa 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-26 Jesus Lozano Jesuslozano0086@icloud.com Des Moines Polk Iowa Sheanah Wright Derek Mullins Signed (1) The employer does not elect the employers’ liability coverage. Jesus Lozano Jesuslozano0086@icloud.com Owner Des Moines Polk Iowa Sheanah Wright Derek Mullins Signed
960 2022-03-09 11:13 Anonymous (not verified) 65.144.174.26 Jesus Munoz Proprietorship 401 6th Ave Coralville, IA 52241 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-09 Jesus Munoz jesus131805@gmail.com Coralville Johnson Iowa Juan Cruz Marlon Cruz Signed (1) The employer does not elect the employers’ liability coverage. Jesus Munoz jesus131805@gmail.com Self Coralville Johnson Iowa Juan Cruz Marlon Cruz Signed
1006 2022-03-25 10:26 Anonymous (not verified) 107.115.239.110 Jesus ojeda Limited Liability Company 866 40th Ave Bettendorf IA 52722 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-25 Jesus Ojeda jesusojeda386@gmail.com 2112 20 1/2 Ave Rock Island 61201 United States Illinois Cody Dunbar Tiffani branham Signed (1) The employer does not elect the employers’ liability coverage. Cody Dunbar cdunbar@leaffilter.com Install manager 866 40th Ave Bettendorf IA 52722 United States Iowa Jordan Nisiewicz Tiffani Branham Signed
56 2020-02-07 15:17 Anonymous (not verified) 204.153.176.73 J*M Fuels, LLC Limited Liability Company 600 W Bremer Avenue, Waverly IA 50677 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-07 Jim Johnson mattjohnson7555@gmail.com Jackson TWP Butler Iowa Ty Burke Lori Frerichs Signed (1) The employer does not elect the employers’ liability coverage. Ty Burke tburke@acceladvantage.com Agent Waverly IA United States Tony Pollastrini Lori Frerichs Signed
602 2021-08-13 22:49 Anonymous (not verified) 208.38.230.125 Granite & More Limited Liability Company 4730, Tremont Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-14 Jin Chen clteam563@gmail.com Davenport IA United States Jin Chen Betty Song Signed (1) The employer does not elect the employers’ liability coverage. Hong Le clteam563@gmail.com Self Davenport Scott Iowa Jin Chen Betty Song Signed
1487 2023-02-27 22:12 Anonymous (not verified) 94.188.207.224 Panda garden Proprietorship 105 2nd Ave se cresco ia 52136 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-10 Jing Chen jingchen9968@gmail.com Cresco Howard Iowa Leyang Zhou Guy Chen Signed (1) The employer does not elect the employers’ liability coverage. Jing Chen jingchen9968@gmail.com Self Cresco Howard Iowa Leyang zhou Guy Chen Signed
2010 2024-01-30 11:46 Anonymous (not verified) 94.188.207.230 Kevin & Jlynn Jones Proprietorship 1500 15th St. Milford Ia 51351 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-30 Jlynn Jones KEVINMJONES81@GMAIL.COM Milford Dickinson Iowa Tami Klein Joseph Loring Signed (1) The employer does not elect the employers’ liability coverage. Kevin & Jlynn Jones KEVINMJONES81@GMAIL.COM Self Milford Dickinson Iowa Tami Klein Joseph Loring Signed
1557 2023-04-05 20:42 Anonymous (not verified) 94.188.207.228 Nava lawn care and junk hauling Limited Liability Company 220 2nd Street West Des Moines Iowa 50265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-05 Joan Nava Becerril jnb.2499@gmail.com West Des Moines IA United States Aylin Silva Garcia Arjan Silva Signed (1) The employer does not elect the employers’ liability coverage. Joan Nava Becerril info@navalawnandjunk.com OWNER West Des Moines IA United States Aylin Silva Garcia Arjan Silva Signed
1225 2022-07-23 18:01 Anonymous (not verified) 174.242.224.34 Ottumwa mow & snow llc Limited Liability Company 11443 Bladensburg Rd Ottumwa IA 52501 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-23 JoAnn laBella joannlabella@gmail.com Ottumwa Wapello IA Doug Knott Katy Knott Signed (1) The employer does not elect the employers’ liability coverage. RJ Hallman rjhallman@fedins.com Insurance Owatonna Steele MN Katy knott Doug knott Signed
1226 2022-07-23 18:02 Anonymous (not verified) 174.242.224.34 Ottumwa mow & snow llc Limited Liability Company 11443 Bladensburg Rd Ottumwa IA 52501 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-23 JoAnn laBella joannlabella@gmail.com Ottumwa Wapello IA Doug Knott Katy Knott Signed (1) The employer does not elect the employers’ liability coverage. RJ Hallman rjhallman@fedins.com Insurance Owatonna Steele MN Katy knott Doug knott Signed
1082 2022-04-29 12:28 Anonymous (not verified) 75.162.101.109 Jodi Trewet Proprietorship 11920 NW 114th Ln Granger, IA 50109 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-29 Jodi Trewet jtrewet@yahoo.com Granger IA United States Mark Trewet Tyler Trewet Signed (1) The employer does not elect the employers’ liability coverage. Jodi Trewet jtrewet@yahoo.com Same Granger Polk IA Mark Trewet Tyler Trewet Signed
300 2020-10-30 10:51 Anonymous (not verified) 216.51.132.207 Joe Kann & Luke Kann Partnership 32256 Leaf Rd Guttenberg IA 52052 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-28 Joe Kann kannbros1895@gmail.com Guttenberg Clayton Iowa Jerry J Rochford Nicole L Parker Signed (1) The employer does not elect the employers’ liability coverage. Joe Kann kannbros1895@gmail.com owner Guttenberg Clayton Iowa Jerry J Rochford Nicole L Parker Signed
2171 2024-04-22 14:09 Anonymous (not verified) 94.188.205.176 Messer's concrete cutting Proprietorship 714 Summer 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. 2024-04-22 Joe messer josephdmesser@gmail.com Burlington IA United States Joe messer Joe messer Signed (1) The employer does not elect the employers’ liability coverage. Joe messer josephdmesser@gmail.com Owner Burlington IA United States Joe messer Joe messer Signed
623 2021-08-30 15:03 Anonymous (not verified) 174.198.77.231 Joe Dawson Proprietorship 1088, Dogwood Avenue I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-30 Joe R Dawson joerdawson@gmail.com Coon Rapids IA United States Linda Doran Megan Specht Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Joe R Dawson joerdawson@gmail.com Owner Coon Rapids IA United States Linda Doran Megan Specht Signed
302 2020-10-31 13:04 Anonymous (not verified) 173.17.230.149 Absolute Construction Partnership 3720 Patricia Drive, Urbandale, Iowa 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-31 Joe Simpson jrsimpson27@gmail.com Urbandale Polk Iowa Alex Vanderbeek James Nelson Signed (1) The employer does not elect the employers’ liability coverage. Joe Simpson jrsimpson27@gmail.com self Urbandale Polk Iowa Alex Vanderbeek James Nelson Signed
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
686 2021-10-20 18:43 Anonymous (not verified) 173.27.196.168 Royal Flooring Proprietorship 11801 Hickman Rd Urbandale, IA 50323 United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-20 Joel Cisneros auroraramos476@gmail.com Des Moines Polk county Iowa Aurora Cisneros Maria Arroyo Signed (1) The employer does not elect the employers’ liability coverage. Royal Flooring cisnerostile476@gmail.com Employee Clive Dallas Iowa Aurora Cisneros Maria Arroyo Signed
953 2022-03-07 16:13 Anonymous (not verified) 173.27.196.168 Joel Cisneros Proprietorship 721 e madison ave Des Moines Iowa 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-07 Joel Cisneros cisnerostile476@gmail.com Des monies Polk county Iowa Aurora Cisneros Romualda Ramos Signed (1) The employer does not elect the employers’ liability coverage. Joel Cisneros cisnerostile476@gmail.com Employee Des Moines Polk Iowa Aurora Cisneros Romualda Ramos Signed